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Tice JA, Ettinger B, Ensrud K, Wallace R, Blackwell T, Cummings SR. Phytoestrogen Supplements for the Treatment of Hot Flashes: The Isoflavone Clover Extract (ICE) Study: A Randomized Controlled Trial. JAMA. 2003;290(2):207–214. doi:10.1001/jama.290.2.207
Author Affiliations: Division of General Internal Medicine (Dr Tice), Prevention Sciences Group (Drs Blackwell and Cummings), Department of Medicine (Drs Tice, Blackwell, and Cummings), University of California, San Francisco; Division of Epidemiology, School of Public Health, University of Minnesota and Division of General Internal Medicine, and Department of Medicine, Veterans Affairs Medical Center, Minneapolis (Dr Ensrud); Division of Research, Kaiser Permanente Medical Care Program, Oakland, Calif (Dr Ettinger); Preventive Intervention Center, Department of Epidemiology, University of Iowa, Iowa City (Dr Wallace).
Context Clinical trials demonstrating increased risk of cardiovascular disease
and breast cancer among women randomized to hormone replacement therapy have
increased interest in other therapies for menopausal symptoms. Dietary supplements
containing isoflavones are widely used as alternatives to hormonal therapies
for hot flashes, but there is a paucity of data supporting their efficacy.
Objective To compare the efficacy and safety of 2 dietary supplements derived
from red clover with placebo in symptomatic menopausal women.
Design, Setting, and Participants Randomized, double-blind, placebo-controlled trial of menopausal women,
aged 45 to 60 years, who were experiencing at least 35 hot flashes per week.
The study was conducted between November 1999 and March 2001 at 3 US medical
centers and included women who were recently postmenopausal (mean [SD], 3.3
[4.5] years since menopause) experiencing 8.1 hot flashes per day. Women were
exluded if they were vegetarians, consumed soy products more than once per
week, or took medications affecting isoflavone absorption.
Intervention After a 2-week placebo run-in, 252 participants were randomly assigned
to Promensil (82 mg of total isoflavones per day), Rimostil (57 mg of total
isoflavones per day), or an identical placebo, and followed-up for 12 weeks.
Main Outcome Measure The primary outcome measure was the change in frequency of hot flashes
measured by participant daily diaries. Secondary outcome measures included
changes in quality of life and adverse events.
Results Of 252 participants, 246 (98%) completed the 12-week protocol. The reductions
in mean daily hot flash count at 12 weeks were similar for the Promensil (5.1),
Rimostil (5.4), and placebo (5.0) groups. In comparison with the placebo group,
participants in the Promensil group (41%; 95% confidence interval [CI], 29%-51%; P = .03), but not in the Rimostil group (34%; 95% CI, 22%-46%; P = .74) reduced hot flashes more rapidly. Quality-of-life
improvements and adverse events were comparable in the 3 groups.
Conclusion Although the study provides some evidence for a biological effect of
Promensil, neither supplement had a clinically important effect on hot flashes
or other symptoms of menopause.
Hot flashes are the primary reason that women seek medical attention
for menopausal symptoms. The recent results from the Women's Health Initiative1 and long-term follow-up from the Heart and Estrogen/progestin
Replacement Study2,3 demonstrating
an increased risk of cardiovascular disease and breast cancer among women
randomized to hormone therapy are likely to reduce the use of hormones for
relief of menopausal symptoms. Dietary supplements containing isoflavones
derived from soy or red clover are heavily marketed as alternative treatments
for menopausal symptoms. In Asia, only 10% to 20% of women experience hot
flashes compared with 70% to 80% of women in Western countries.4-7 A
popular hypothesis to explain this difference is that isoflavones found in
soy, a staple in the traditional Asian diet, influence the body's response
to the changing hormonal levels of menopause.8 Isoflavones
are polyphenol compounds structurally related to estrogens that have been
shown to bind to estrogen receptors9 and appear
to act as partial agonists in some tissues and antagonists in others. They
have a higher binding affinity for estrogen-receptor β than for estrogen-receptor α.10-12
Dietary supplements containing isoflavones from soy or red clover are
widely marketed for menopausal symptoms and are increasingly being used by
women in the United States as an alternative to estrogen.13-16 Most
published studies of isoflavones for relief of menopausal symptoms have investigated
the effectiveness of soy products.17-28 Dietary
supplements derived from red clover contain additional isoflavones (biochanin
A, formononetin) not found in soy, which may have additional biological activity.
On the other hand, red clover lacks components of soy that may contribute
to soy's biological effects. There are few published data29-33 and
no published large clinical trials on the effects of these compounds on menopausal
symptoms and quality of life. Furthermore, many clinicians and the public
have expressed concern about the safety of dietary supplements.
We initiated the Isoflavone Clover Extract study to investigate whether
2 dietary supplements derived from red clover were safe and more effective
than placebo at reducing hot flashes and improving menopausal quality of life
in symptomatic postmenopausal women.
Women were recruited at 3 academic clinical research sites located in
Oakland, Calif; Minneapolis, Minn; and Iowa City, Iowa. The study was administered
through a coordinating center at the University of California, San Francisco.
The institutional review boards at each clinical site and at the coordinating
center approved the study protocol. All participants gave written informed
Women were recruited from the general population through newspaper and
radio advertising, flyers posted in clinics and at health fairs, and directed
mailings. Participants were enrolled between November 1999 and November 2000.
All participants were aged 45 to 60 years, experiencing at least 35 hot flashes
per week, and had a follicle-stimulating hormone (FSH) level of 30 mIU/mL.
Eligible women had either documented bilateral oophorectomy or at least 2
consecutive months of amenorrhea prior to enrollment with at least 6 months
of amenorrhea in the year prior to entry. Women were excluded from the study
if they were vegetarian, consumed soy products more than once per week, took
medications affecting isoflavone absorption (antibiotics, antacids) or hormonal
preparations during the 3 months prior to enrollment, had significant gastrointestinal
disease, drank more than 2 alcoholic beverages per day, were allergic to red
clover, were regular users of dietary supplements containing isoflavones,
or consumed less than 80% of the expected study tablets during the 2-week
placebo run-in period.
The 2 study supplements, Promensil and Rimostil, and identical placebo
were prepared by the manufacturer (Novogen Ltd, Sydney, Australia) and sent
to a central research pharmacy for packaging and labeling. The central pharmacy
was not involved in the study design or participant monitoring. Promensil
contains a higher proportion of biochanin A and genistein. Rimostil contains
a higher proportion of formononetin and daidzein. An independent laboratory
(Sigma Pharmaceuticals, South Croydon, Australia) verified the contents of
the study tablets. Placebo tablets contained less than 0.04 mg of total isoflavones
per tablet; Promensil tablets contained an average of 41.0 mg of total isoflavones
(range, 37.0-43.0 mg); and Rimostil tablets contained an average of 28.6 mg
of total isoflavones (range, 25.6-31.4 mg). Participants were instructed to
take 2 tablets once daily.
The randomization schedule was prepared by the central pharmacy using
computer-generated randomization in blocks of 6, stratified by clinical site.
The allocation schedule was maintained at the pharmacy. Each site received
numbered containers and distributed them sequentially at randomization. The
clinical center principal investigators, their staff, the participants, and
the coordinating center principal investigator and staff were all blinded
to treatment allocation until the last participant completed her close-out
visit and the data clean-up was finished.
Staff from each of the clinical sites attended a training session organized
by the coordinating center to ensure standard administration of the study
protocol and to certify staff on measurement techniques. Participant eligibility,
according to the selection criteria previously described, was assessed at
an initial screening telephone call and 2 clinic visits. At the first clinic
visit, weight, height, pulse, and blood pressure were measured according to
a standard protocol. Body mass index (BMI) was calculated as weight in kilograms
divided by the square of height in meters. Demographics, reproductive history,
smoking, and alcohol consumption were assessed by participant self-report.
A supply of placebo tablets was distributed for a 2-week run-in phase. The
participants were informed that the run-in tablets were placebos and were
the same as those that were to be used in the main study. At the end of the
run-in phase, baseline questionnaires and physical examination were completed.
A 24-hour urine sample was collected and willing participants, who were at
least 80% compliant with the run-in regimen, were randomized to receive a
dietary supplement or placebo.
Participants were contacted by telephone at 1, 4, and 8 weeks to encourage
compliance, assess adverse effects, verify concurrent medications, and obtain
follow-up information on hot flashes and other symptoms. At 12 weeks, the
trial participants returned to the clinic sites for a full evaluation including
repeat of the quality-of-life measures, physical examination, blood draw,
and 24-hour urine collection. Compliance was assessed by pill count.
Women participating in the study were given hot flash diary cards to
record the number of hot flashes and night sweats they experienced on a daily
basis.34 Hot flash counts were averaged for
each week. If more than 3 days during a week had missing data, the average
for that week of the study was treated as missing.
Changes in quality of life were assessed using the Greene Climacteric
Scale, a validated instrument for women experiencing symptoms attributed to
menopause.35 This instrument has 6 subscales
specifically designed to assess menopausal symptoms. The Greene questionnaire
was completed at randomization and at 1, 4, 8, and 12 weeks after randomization.
Fasting serum, 24-hour urine collections, and second morning void urine
specimens were collected prior to randomization and at study closeout. All
specimens were aliquoted at the clinical sites, frozen at –80°C,
and sent to a central laboratory for storage (Esoterix Inc, Calabas Hills,
Calif). Paired 24-hour urine specimens were analyzed for isoflavone excretion
(genistein, daidzein, biochanin A, formononetin, o-desmethyl-angolensin, and
equol) by laboratory personnel blinded to treatment allocation (Australian
Government Analytical Laboratories, Canberra). Total isoflavone excretion
was calculated as the sum of the individual isoflavone excretion amounts.
We hypothesized that the isoflavone supplements would be more effective
than placebo in reducing hot flashes. The study was designed to have 90% power
to detect at least a 15% greater reduction in hot flash frequency in the active
treatment arms compared with the placebo arm. We assumed that women taking
placebo would have a 25% decrease in the number of weekly hot flashes.
We analyzed differences in rate of change of weekly hot flash counts
over the 12-week treatment period using a random coefficients regression model
with a quadratic effect for each treatment through time. Each participant
had her own random intercept and slope. Separate analyses were done comparing
each phytoestrogen supplement with placebo. No analysis combining the 2 active
treatment arms was planned or performed. The primary analysis was an intention-to-treat
analysis that included all patients who were randomized. No adjustment for
baseline covariates was planned for the primary analysis. Models were also
analyzed including covariates known to be associated with hot flashes. A secondary
per protocol analysis was performed, which included only participants who
had hot flash count data available for the 12th week after randomization,
who had at least 80% compliance with study tablets by pill count, and whose
total isoflavone excretion was less than 1 mg/24 hours at baseline and remained
less than 1 mg/24 hours at closeout (placebo group) or was more than 1 mg/24
hours (phytoestrogen groups). The remaining prespecified subgroups were time
since menopause (5 years vs >5 years), BMI (median vs >median), and FSH level
(median vs >median). They were analyzed to identify women who might particularly
benefit from either phytoestrogen supplements. Because isoflavone excretion
was not normally distributed, Spearman correlation was used to assess the
association of change in hot flash number with change in urinary isoflavone
Scores for the subscales of the Greene Climacteric Scale were calculated
using the standard method described by Greene.35 Data
are reported using the last observation carried forward. Alternative strategies
for imputation of missing values did not affect the results nor did per protocol
Baseline characteristics were summarized by treatment group. For continuous
variables, means were compared using analysis of variance for normally distributed
variables and the Kruskal-Wallis test for variables with skewed distributions.
Categorical variables were compared using the χ2 test. For
all primary and secondary outcomes, outliers were included in the principal
analysis. Secondary analyses excluding participants with values higher than
3 SDs from the mean did not alter the results and have not been presented
in this article. Safety data was tabulated according to initial randomization
assignment. We reported all adverse events occurring in at least 3% of the
women and those that differed across arms (P = .05).
The Fisher exact test was used to examine the difference in rates of occurrence
between the 3 groups. A 2-tailed P value of less
than .05 was considered statistically significant for all analyses.
Among 1191 women screened by telephone (Figure 1), 870 were ineligible. The principal reasons for ineligibility
included too few hot flashes (n = 223), not interested in participation (n
= 205), medical conditions and medications (n = 192), dietary exclusions (n
= 104), and not being menopausal (n = 94). Of the 321 women who were invited
to the clinic for blood tests and a 2-week placebo run-in, 69 were ineligible.
The principal reasons for ineligibility included too few hot flashes (n =
28), FSH level of less than 30 mIU/mL (n = 18), and not interested in participation
(n = 11). Only 3 women were ineligible for randomization due to inadequate
adherence during the run-in. Participants were randomized to Promensil (n
= 84), Rimostil (n = 83), or placebo (n = 85). All participants received treatment
as allocated. Two participants in each arm did not complete the 12-week active
phase of the study.
At baseline, the participants did not differ across groups by age, demographic
characteristics, reproductive factors, or FSH level (Table 1; all P>.05). On average, the women
were recently postmenopausal, experiencing about 8 hot flashes per day, and
Ninety-eight percent (246/252) of the women completed the full 12 weeks
of the study. The participants took 97% of the expected number of tablets
by count of the returned tablets, and 98% of the participants took at least
80% of the tablets. Compliance did not differ across groups (P = .21). Only 1 woman dropped out because of an adverse event (nausea
in a participant randomized to Rimostil).
The reduction in mean hot flash count at 12 weeks was 41% (95% confidence
interval [CI], 29%-51%) for the Promensil group, 34% (95% CI, 22%-46%) for
the Rimostil group, and 36% (95% CI, 26%-45%) for the placebo group (Table 2). The change in hot flash counts
from randomization to closeout was significant for all 3 groups (P<.001). However, the hot flash reductions in the phytoestrogen
groups were not statistically different from placebo at 12 weeks (P>.20). The reduction in hot flashes was faster for Promensil compared
with placebo (Figure 2; P = .03). The comparable analysis for Rimostil vs placebo found that
the rate of reduction in hot flashes was similar for the 2 groups (P = .74). Adjusting for baseline covariates including study site, season,
FSH level, age at randomization, age at menopause, and time since menopause
did not change the results. On average, women in all 3 groups were still experiencing
more than 5 hot flashes per day at the end of the 12-week study period.
Per protocol results (n = 197) were similar to the intention-to-treat
analyses. There was some evidence that the benefit of the phytoestrogen supplements
in reducing hot flash frequency was most pronounced for women above the median
BMI. For Promensil, the reduction in hot flashes over 12 weeks was 49% (95%
CI, 35%-63%) for women above the median BMI (25.1) and 30% (95% CI, 16%-44%)
for thinner women (BMI <25) (P for interaction
= .09). For Rimostil, the reduction in hot flashes over 12 weeks was 45% (95%
CI, 32%-59%) for overweight women and 22% (95% CI, 7%-37%) for thinner women
(P for interaction = .02). For women in the placebo
group, the reduction in hot flashes over 12 weeks was 32% (95% CI, 21%-42%)
for overweight women and 40% (95% CI, 26%-55%) for thinner women. There were
no significant interactions for the subgroups defined by FSH level or years
Among the 241 women with paired 24-hour urine results available, there
was no statistically significant correlation of change in hot flash number
with change in total isoflavone excretion (ρ = .01; P = .84) or with change in the excretion of genistein, daidzein, biochanin
A, formononetin, o-desmethyl-angolensin, or equol.
Compared with age- and sex-matched population normative data,36 women entering this study reported high levels of
distress on the vasomotor scale (mean [SD], 3.6 [1.2]), but lower distress
on the psychological (mean [SD], 6.0 [4.4]) and somatic (mean [SD], 2.8 [2.4])
scales. Over the 12-week treatment period, there were significant improvements
from baseline in all 3 groups, but there were no statistically significant
differences between groups on any of the Greene scales (Table 3).
Adverse events occurring in at least 3% of the participants are shown
in Table 4. There was no statistically
significant association of either of the dietary supplements with adverse
events; the only adverse event approaching statistical significance was headache
(P = .10 for Rimostil vs placebo; P = .12 for Promensil vs placebo), which was more common among women
randomized to placebo. There was no association with vaginal spotting (3.6%
for Promensil group, 1.2% for Rimostil group, and 2.4% for placebo group)
and there were no reports of breast tenderness, venous thrombosis, pulmonary
embolism, myocardial infarction, stroke, fracture, or gallbladder disease.
There were no treatment-related changes in weight, blood pressure, or heart
rate (P = .28).
The Isoflavone Clover Extract study was a large, multicenter, randomized,
placebo-controlled trial of red clover extracts in postmenopausal women reporting
hot flashes. At the end of 12 weeks, the reduction in hot flashes was similar
for the 3 groups. Promensil, but not Rimostil, reduced the frequency of hot
flashes more rapidly than placebo. The reduction was modest (41% over 12 weeks),
but similar in size to that found in other studies of phytoestrogen supplements.17-29,37
There were no significant differences for either supplement compared
with placebo in 6 domains of menopause symptoms assessed at regular intervals
by the Greene Climacteric Scale. However, all 3 groups reported improvements
in their symptom scores. The magnitude of these changes were between 40% and
94% of the differences reported between perimenopausal women and premenopausal
women in a population-based study validating these scales.36 This
suggests that women in all 3 arms experienced improvements in quality of life
that were clinically important. The magnitude of the improvements in hot flashes
and other menopausal symptoms in the placebo group highlight the importance
of placebo-controlled clinical trials in evaluating the efficacy of potential
therapies for menopausal symptoms.
The red clover extracts were well tolerated by the participants. We
did not find any trend toward an association of these dietary supplements
with adverse outcomes. However, the 12-week intervention period was too short
to assess the risk for endometrial hyperplasia, breast cancer, venous thromboembolic
disease, cardiovascular disease, or other potentially serious adverse events,
which have been associated with estrogenic therapies. Potential long-term
benefits also could not be evaluated. Furthermore, with only 252 participants
followed-up for 3 months, we had limited power to detect rare adverse events.
Most prior studies of isoflavones have used soy products.17-28 The
results have been mixed: some studies found a modest benefit (10%-15%) compared
with placebo17-19,21,24,25,32,33 and
others did not.20,22,23,26-29 A
small, uncontrolled study of a red clover extract reported a 56% decrease
in hot flashes.31 Two small randomized clinical
trials of the same extract found more modest reductions in hot flash frequency
(22%-34%) that were similar to those observed in the placebo group,29,30 but 2 more recent randomized trials
have reported statistically significant reductions of 44%33 and
49%.32 Several studies have suggested that
once daily consumption of isoflavones is not sufficient for optimal symptom
relief given that the half-life of isoflavones is between 6 and 10 hours.38-40 This may explain
some of the heterogeneity in the results: a twice-a-day dose schedule might
be efficacious. There has also been a wide range in the amount of total isoflavones
used in these studies. Although the amount of total isoflavones used in the
Isoflavone Clover Extract study were relatively high, it is possible that
higher doses are needed to have a clinically important effect. The reduction
in hot flashes reported in the positive studies (40%-54%)14-16,18,21,22,32 has
been smaller than the 77% reduction reported in a meta-analysis of clinical
trials using hormone replacement therapy.41 Furthermore,
a randomized clinical trial of soy found that adding 0.625 mg of conjugated
equine estrogens after 6 weeks of soy therapy resulted in a statistically
significant additional reduction in hot flashes.24 As
in the present study, those who have demonstrated a statistically significant
reduction in hot flashes with phytoestrogens generally report a tendency toward
early benefit that decreases after 8 to 12 weeks of therapy.19,25
The mechanism of action of these supplements is unclear but is thought
to be primarily through estrogenlike effects of the isoflavones. Isoflavones
are structurally similar to estradiol, binding to both estrogen-receptor α
and estrogen-receptor β, and appear to have tissue-specific effects like
selective estrogen-receptor modifiers.9-12 They
have been shown to affect the catabolism of estrogens42 and
may affect estrogen-receptor expression.43 Several
nonhormonal mechanisms have been demonstrated for isoflavones including tyrosine
kinase inhibition, antioxidant activity, and effects on ion transportation.44
Given that the overall reduction in hot flashes was not different between
the 3 treatment groups and that the effect of isoflavone supplementation on
rate of reduction was seen only for Promensil and not Rimostil, it could be
argued that the results are due to chance alone and not the biological effects
of the isoflavones. Alternatively, the results may indicate that the biochanin
A and genistein found in higher concentrations in Promensil are more effective
for hot flash reduction than the formononetin and daidzein found in Rimostil.
Genistein is also present in higher concentrations than daidzein in soy, which
is the basis of the traditional Asian diet.45,46
We examined several subgroups to explore whether certain populations
might receive greater benefit from isoflavones derived from red clover. Heavier
women appeared to receive more benefit from the isoflavone supplements while
the changes in the placebo group were similar to a placebo effect. This was
contrary to our expectation and needs to be reproduced in other studies. Postmenopausal
women with higher BMIs tend to have higher circulating estrogens due to conversion
of androgens to estrogens by aromatase in adipocytes.47 We
hypothesized that the isoflavones might have greater effects in an estrogen-poor
environment, although the relationship between estrogen level and menopausal
symptoms has been inconsistent.47,48 Several
studies have reported a higher incidence of hot flashes in women with higher
BMIs.49,50 This may be due to
the insulating effects of body fat leading to a more rapid rise in core body
temperature, which then triggers hot flashes.51 It
is unclear why phytoestrogens would have greater efficacy in overweight women.
This study has several limitations. Most of the study participants were
white and highly educated, which limits the generalizability of the results
to other socioeconomic or racial groups. In addition, the women were all postmenopausal.
Thus, the results may not apply to perimenopausal women, which is usually
the period when women experience the most frequent and severe hot flashes.
Furthermore, we required women to document at least 35 hot flashes per week
to be eligible for this study; less symptomatic women may or may not benefit.
This study is the largest randomized clinical trial of red clover extracts
in postmenopausal women. Compliance with therapy was exceptionally high (98%)
and the drop-out rate was low (2%). We attempted to recruit from a broad cross-section
of the population through media advertising and mailings to age-eligible women,
rather than recruiting primarily from menopause clinics or referral centers.
In conclusion, the overall reduction in hot flashes after 12 weeks of
treatment was modest and similar between women in all 3 groups. Promensil
reduced hot flashes more rapidly than placebo. Although the study provides
some evidence for a biological effect of Promensil, neither supplement had
a clinically significant effect on hot flashes or other menopausal symptoms
when compared with placebo.
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