Effects of an Herbal Medication Containing Bee Products on Menopausal Symptoms and Cardiovascular Risk Markers: Results of a Pilot Open-uncontrolled Trial

Abstract

Objectives

Fifty-five postmenopausal women with menopausal complaints were treated with the food supplement Melbrosia for 3 months. Menopausal symptom evaluation scales and psychological questionnaires were administered, and cardiovascular disease markers in blood were analyzed at the beginning and the end of the trial.

Setting

The perimenopausal care unit of Second Obstetrics and Gynecology Hospital, Sofia, Bulgaria

Design

The study was an open, multicenter, uncontrolled, prospective observation study. The subjective symptoms questionnaires administered before Melbrosia treatment and after 3 months of treatment were Kupperman Score, Zerssen Symptom List, Zung Depression Score, and Frankfurt Self-concept Scale (self-assessment test, problem-solving test, self-esteem test, and irritability test). The blood levels of high-density lipoproteins (HDL), low-density lipoproteins (LDL), triglycerides (TG), total cholesterol (TC), vascular cell adhesion molecule-1 (VCAM-1), and C-reactive protein (CRP) levels were measured in a subgroup of patients.

Results

Treatment of postmenopausal women with Melbrosia led to a statistically significant reduction in the Kupperman score, Zerssen's Symptoms List, and Zung Depression Score. The Frankfurt Self-concept Scale revealed significant improvement in problem-solving, no change in self-assessment and self-esteem, and worsening of irritability. Treatment with Melbrosia significantly reduced TC and LDL and significantly elevated HDL and TG. There were nonsignificant changes of serum VCAM-1 and CRP levels in patients treated with Melbrosia.

Conclusions

The presented data suggest that Melbrosia may offer a potential alternative to hormone therapy for the treatment of menopausal symptoms. However, because of this study's uncontrolled, open- label methodology, no cause-and-effect inferences can be drawn until a larger, longer-term, blinded, placebo-controlled, randomized clinical trial is performed.

Introduction

Hormone therapy (HT) is a well-established treatment for menopausal symptoms, in particular hot flashes[1] and urogenital atrophy.[2] It also has beneficial effects on the skeleton and reduces the risk of colon cancer; its effects on the cardiovascular system are a matter of debate.[3-5] The effect of HT on Alzheimer's disease is not clear and is still a matter of scientific investigation. Some studies[6,7] suggest that HT may decrease the risk of the disease, but others show no effect.[8,9]

Despite some important health benefits associated with HT, many women never use it because of contraindications or personal choice, and some discontinue therapy after short-term use because of side effects. Recently, data from the Women Health Initiative (WHI) study raised public concern about HT and the safety of this treatment.[5] For these reasons, there is a growing interest in alternative therapies. One alternative employs phytoestrogens -- nonsteroidal plant compounds that are structurally or functionally similar to estrogens and may have similar beneficial effects. Examples of phytoestrogens, such as lignans and flavonoids, are found in many fruits, vegetables, and grains. These substances have a 2-phenylnaphthaline-type chemical structure and bind to estrogen receptors in vitro.[10] It has been postulated that some phytoestrogens also have antiestrogenic properties, which may be partially explained by their competition with endogenous 17-beta estradiol for estrogen receptors.[11] A wealth of empiric data on the effects of phytoestrogens have been reported. In a study of the diets and phytoestrogen excretion in American, Finnish, and Japanese women,[14] the urinary excretion of phytoestrogens from Japanese women was 100-fold to 1000-fold higher than that from American and Finnish women who consumed a Western diet. The higher excretion of the isoflavones in urine was associated with the intake of soy products such as tofu, miso, soybeans, and boiled beans. In 1 study, dietary supplementation with isoflavones or lignans had an estrogenic effect, as shown by the maturation of vaginal epithelium on cytology,[15] but another trial[16] did not confirm this effect. A recent randomized, controlled, crossover study that compared the effects of phytoestrogens with placebo on menopausal symptoms and quality of life showed that phytoestrogens were no better than placebo and did not cause significant changes in the levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, and sex hormone-binding globulin.[17]

A possible mechanism for increased cardiovascular risk in the menopause is the loss of antioxidant effects of endogenous estrogens. It has been shown that classic risk factors (eg, hypertension, hypercholesterolemia, and smoking) increase oxidative stress in the arterial wall.[18] One of the consequences is the activation of nuclear factor kappa B (NFkB) and the induction of redox sensitive genes.[19] Endothelial cells respond to this activation with an increased expression of cellular adhesion molecules (CAM).[20] Inflammation is thought to play a key role in the pathogenesis of atherosclerosis. An increased level of C-reactive protein (CRP) as a marker of endothelial activation and inflammation has been reported in postmenopausal women.[21] In addition, it has been suggested that increased CRP concentration may reflect the inflammatory action of exogenous estrogens on the arterial wall and that this could explain the increase of cardiovascular risk during the first years of taking some forms of HT that was reported in several clinical trials.[6,22] Previous studies have shown that HT reduces the concentrations of CAM[23,24] and increases CRP levels.[25]

Some herbs contain substances that have well-recognized biological effects -- for example, Digitalis purpurea (digoxin), Taxus brevifolius (paclitaxel), and Hypericum perforatum (St John's wort, hypericin). The medication studied in this trial, Melbrosia, contains a combination of flower pollen, perga (fermented flower pollen), and royal jelly. It is registered as a food supplement in Europe and in some South American countries. The main active ingredients of Melbrosia are phytosterols, phytoestrogens (lignans and flavonoids), amino acids, oligopeptides, and enzymes. A previous placebo-controlled trial investigated the effects of Melbrosia on postmenopausal women's behavior[26]; however, the effects on menopausal symptoms, serum lipid profiles, and atherosclerosis risk factors have not been investigated. Thus, the aim of the study was to test the efficacy of Melbrosia for the treatment of menopausal symptoms (symptoms study) and to determine whether it affects TC, TG, LDL, HDL, sVCAM-1, and CRP blood serum levels (metabolic study).

Materials and Methods

Subjects

Healthy postmenopausal women with moderate to severe typical menopausal symptoms, who had been referred to 3 menopause clinics in Sofia, Bulgaria, between November 2000 and November 2001, were invited to take part in this prospective, open-label, uncontrolled, prospective, observational study. Sixty women agreed, and written informed consent was obtained. Women with a history of endocrine, metabolic, liver, renal, or neoplastic disease, and women who had used HT in the previous 6 months, were excluded from the recruitment list. Full medical history was taken and a complete physical examination was performed. Other inclusion and exclusion criteria were set according to the institutional protocol in each center. The institutional ethics committee approved the study. Demographic characteristics and inclusion and exclusion criteria are presented in (Table 1) and (Table 2). Our population consisted of low-risk, generally young and healthy women with recent menopause. As the study grant could cover the laboratory costs for 30 patients only, the first 30 women who gave informed consent were included in the metabolic part of the study. Thus, 60 women took part in the questionnaire component of the study (symptoms study), and 30 took part in the metabolic study.

Table 1.

Demographic Characteristics

	Study Group (n = 60)	Metabolic Group (n = 30)*
Mean age, yrs (range)	48.8 (39-58)	47.3 (39-55)
Mean parity (range)	1.4 (0-2)	1.4 (0-2)
Yrs since menopause (range)	1.62 (2-10)	2.2 (2-9)
Patients with hysterectomy, n (%)	5 (8.8)	2 (6.6)
Cigarettes per day, n (range)	9 (0-40)	9 (0-40)

*The first 30 women out of the 60 who gave informed consent were enrolled in the metabolic study.

Table 2.

Inclusion and Exclusion Criteria

Inclusion criteria	Study-specific	Institutional
Menopause – at least 12 mos after the last spontaneous period	Yes
Typical menopausal symptoms	Yes
Signed informed consent		Yes
Exclusion criteria	Study-specific	Institutional
HT in the last 6 mos	Yes
Antihypertensive or antilipemic treatment	Yes
Serious disease requiring hospital stay in the last 2 yrs		Yes
History of cancer, thrombosis	Yes
Psychotropic therapy		Yes
Participation in other trials		Yes

Treatment Protocol

All patients had 3 visits at the menopause clinic: a screening visit, a baseline visit (start of therapy), and a visit after 12 weeks of treatment (end of therapy). All patients (N = 60) were asked to complete symptoms questionnaires at baseline and after 12 weeks of treatment. At baseline and at 12 weeks, blood samples were obtained between 8:00 and 9:00 AM from the 30 women enrolled in the metabolic study. At the screening visit, women were instructed not to eat anything and to drink only water on the night before the baseline visit and on the night before the Week 12 visit when blood samples were due to be taken. On the morning of both visits, all women were asked whether they had complied with the instructions. All women claimed to have been compliant with the instructions in both instances. The patients were treated with 2 capsules of Melbrosia once a day for the first 2 weeks, and then 1 capsule daily for the remaining 10 weeks. They were instructed to take the medication at approximately the same time each day and to complete the questionnaires at the beginning and end of study. Five patients dropped out during the first month of the study due to perceived lack of efficiency of the medication and were not replaced. Three of those 5 were in the subgroup for whom blood was drawn, and so 27 pairs of samples for laboratory analysis were available.

Methods

Symptomatology Questionnaires

Menopause questionnaires (Zung Depression Score,[27] Zerssen's Symptoms List,[28,29] Frankfurt Self-concept Scale,[30,31] and Kupperman Score) were used to assess menopause symptoms. Symptoms in all tests except Kupperman were ranked on a 5-point scale (0 = none, 1 = mild, 2 = moderate, 3 = severe, 4 = extreme). Improvements in symptoms and complaints were reflected by lower scores in Zung Depression Score, Zerssen's Symptoms List, and Kupperman Score. Frankfurt Self-concept Scale (4 components: irritability, problem-solving, self-esteem, and self-assessment tests) are focused on the quality of life (QoL), mood, and psychological symptoms, and higher test scores reflect better life performance. Each patient included in this study had to answer each questionnaire before Melbrosia treatment and after 3 months of treatment. The dropouts were eliminated from the analysis because of missing data.

Serum Markers for Cardiovascular Risk

Blood samples were taken from the first 30 women enrolled in the study at baseline and after 12 weeks of treatment. All samples were drawn between 8:00 and 9:00 AM after an overnight fast using a serum separator tube (Vacutainer, Becton Dickinson) with the patient in a sitting position. After 30 minutes at room temperature, the samples were centrifuged for 10 minutes at 1000 x g. The serum was divided into aliquots and stored at -70° C until analysis. Serum levels of VCAM-1 were measured by quantitative sandwich enzyme immunoassay with a commercially available test (R&D Systems). CRP levels were evaluated by high-sensitivity immunoturbidimetry test with commercially available kits (Dade Behring). Serum levels of total cholesterol, HDL-cholesterol, and triglycerides were measured by enzyme methods (Cobas Mira Plus, Hofmann La Roche). LDL-cholesterol was calculated by the Friedewald formula. To eliminate intra-assay variation, all samples of a given marker were assayed in a single run. The laboratory staff were blinded for sample sequence.

Statistical Analysis

The following analyses were made: (1) for the symptoms study (60 subjects), the questionnaire results at baseline and after 12 weeks of treatment were compared; (2) for the metabolic study (first 30 out of the 60 enrolled), biochemical values were compared at baseline and after 12 weeks of treatment. All data were tested for normality with a 2-sided chi-square test. P values ≤ .05 were considered significant to reject normality, and P values between 0.05 and 0.5 were considered significant to doubt normality; values > 0.5 indicate normal distribution of data. Data that were normally distributed were tested using a paired sample Student's t-test.[32] Data that were not normally distributed were tested using the Wilcoxon-paired sample rank sum test.[33] The null hypothesis is that the mean values (for normal data) and median values (for non-normal data) before and after the treatment are the same (m_X = m_Y), which means Melbrosia has no effect on the studied symptoms and values. Confidence interval of the mean change (m_d = m_y-m_x) is calculated under the assumption of D (change) normality. The statistical analysis was performed using C-Stat, version 5.02.

Results

The statistical results are summarized in (Table 3) and (Table 4). The number of paired observations is given in column 2, the mean values (with standard deviation in brackets) and the medians before and after treatment are shown respectively in columns 3, 4, 6, and 7; whereas the mean values (with standard deviation in brackets) of the change are given in column 5. The 95% confidence interval (CI) of the mean change is shown in columns 9 and 10.

Table 3.

Effects of Melbrosia Treatment on Various Psychological Parameters^*

Parameter	Sample Size	Mean Value (and standard deviation)			Median		P Value (normality) (Pn)†	95% CI of Mean Change (normality)		P Values (impact) (P)‡
		Before	After	Change	Before	After		From	To
1	2	3	4	5	6	7	8	9	10	11
Kupperman	55	25.5 (9.89)	9.89 (5.44)	-15.6 (7.49)	24.5	9.00	.46	-17.6	-13.5	< .001
Zerssen	55	57.7 (13.7)	42.6 (10.6)	-15.0 (12.0)	56.0	39.0	.58	-18.3	-11.8	< .001
Zung Depression Score	55	34.8 (7.9)	28.4 (4.52)	-6.44 (7.58)	35.0	28.0	.0015	-8.51	-4.37	< .001
Problem-solving	55	23.8 (4.23)	25.6 (4.63)	1.78 (3.78)	24.0	26.0	.011	0.759	2.81	.0015
Self-assessment	55	16.8 (3.44.)	17.1 (3.66)	0.291 (2.99)	17.0	17.0	.078	-0.516	1.10	.29
Self-esteem	55	19.7 (2.96)	20.1 (3.02)	0.364 (2.43)	20.0	20.0	.052	-0.293	1.02	.26
Irritability test	55	16.1 (2.43)	14.7 (2.86)	-1.36 (2.52)	16.0	14.0	< .001	-2.05	-0.683	< .001

*Data tested with Student's t-test or Wilcoxon paired sample rank sum test.

^†P values > .5 indicate normal distribution of the data.

^‡P values < .05 indicate statistical significance.

Table 4.

Effects of Melbrosia Treatment on Various Laboratory Parameters^*

Parameter	Sample Size	Mean Value (and standard deviation)			Median		P Value (normality) (Pn)†	95% CI of Mean Change (normality)		P Values (impact) (P)‡
		Before	After	Change	Before	After		From	To
1	2	3	4	5	6	7	8	9	10	11
VCAM-1 (ng/mL)	27	428 (112)	410 (127)	-17.9 (133)	427	429	.10	-70.4	34.5	.46
TC (mmol/L)	27	5.41 (1.19)	5.14 (1.01)	-0.264 (0.684)	5.74	5.15	.63	-0.545	0.00654	0.03
TG (mmol/L)	27	1.25 (0.667)	1.54 (0.902)	0.292 (0.557)	0.950	1.32	.10	0.0714	0.512	.0088
HDL (mmol/L)	27	1.23 (0.329)	1.38 (0.322)	0.142 (0.293)	1.21	1.39	.97	0.0262	0.258	.018
LDL (mmol/L)	27	3.60 (1.02)	3.07 (0.842)	-0.537 (0.807)	3.44	3.15	.33	-0.856	-0.218	.0053
CRP (mg/L)	27	2.35 (2.29)	2.37 (2.35)	0.0243 (1.27)	2.02	1.64	.094	-0.524	0.572	.37

*Data tested with Student's t-test or Wilcoxon paired sample rank-sum test.

^†P values > .5 indicate normal distribution of the data.

^‡P values < .05 indicate statistical significance.

The chi-square test P values for normality (p_n), shown in column 8, indicate that some of the samples are definitely not normal. t-test results are applicable when P_n exceeds 0.5 (to undoubtedly claim normality). Thus, Wilcoxon test P values will be presented in the discussion for all evaluated parameters, except for TC, HDL, and Zerssen, where t-test P values will be presented (since P_n for these parameters exceeds 0.5). All P values for statistical significance are shown in column 11 (at significance level of .05). They will be further referred to as P.

Symptomatology Questionnaires (Table 3)

Fifty-five complete sets of questionnaires were available for analysis. The results of the symptomatology questionnaires show that there is a highly significant reduction in the standardized Kupperman score (P < .001, ), Zerssen's Symptoms List (P < .001), and Zung Depression Score (P < .001) after 12 weeks of Melbrosia treatment. Frankfurt Self-concept Scale showed significant improvement in problem-solving (P = .0015, P_b < .001), no change in self-esteem (P = .26) or self-assessment (P = .29, ), and worsening of irritability (P < .001, ).

Serum Lipids (Table 4)

Twenty-seven sets of samples were available for analysis (3 of the 5 dropouts were in the metabolic group). Treatment with Melbrosia resulted in a significant decrease in TC (P = .03), and LDL (P = .0053). The levels decreased respectively from 5.41 ± 1.19 to 5.14 ± 1.01 mmol/L, and from 3.60 ± 1.02 to 3.07 ± 0.842 mmol/L. A small but significant increase in HDL from 1.23 ± 0.329 to 1.38 ± 0.322 (P = .018) mmol/L and in TG from 1.25 ± 0.667 to 1.54± 0.902 (P = .0088) mmol/L was registered.

VCAM-1 and CRP Levels

The analysis shows that Melbrosia nonsignificantly reduced (P = .46) the expression of VCAM-1 after treatment; the level before therapy was 428 ± 112 ng/mL and 410.4 ± 127 ng/mL after 12 weeks of treatment. No significant changes in the CRP levels (P = .37) after therapy were seen (2.37 ± 2.35 before treatment vs 2.35±2.29 mg/L after 12 weeks of treatment).

Side Effects of Therapy

Only a few patients complained about side effects of the treatment. Two women reported weight gain, which was confirmed at the visits. Melbrosia has 307 kcal per tablet, and changes in body weight are anecdotally reported. Another patient had a transient facial flush and was treated with topical preparation after consultation with a dermatologist. The rash disappeared shortly thereafter. One woman had short-lived gastrointestinal discomfort, which did not interfere with the therapy. None of the side effects caused premature discontinuation of the therapy.

Discussion

This is the first study to investigate the effects of the food supplement Melbrosia (a combination of flower pollen, perga [fermented flower pollen], and royal jelly) on serum lipids, VCAM-1, and CRP levels in postmenopausal women. Although effects of Melbrosia on QoL have been reported,[26] previous studies did not use the variety of symptomatology questionnaires we utilized. In the presented trial, QoL of women treated with the studied medication was evaluated using standardized and well-designed questionnaires of mood and psychological behavior. We were able to show a significant reduction of Kupperman Score, Zerssen's Symptoms List, and Zung Depression Score after 12 weeks therapy with Melbrosia. These data confirm prior findings by Gruber and colleagues[26] showing a significant improvement in the well-being of postmenopausal women treated with this herbal medicine containing bee products. Especially impressive is the 16-point decrease in Kupperman Score. This is similar to the 10- to 19- point decrease that has been reported to occur with estrogen patches and gels or intranasal estrogen preparations.[34-36] Although the self-reported decline in menopausal symptoms is substantial, the nonrandomized design of the study prevents us from attributing the decline to Melbrosia. The already described divergent changes in the Frankfurt Self-concept Scale, reflecting several parameters useful for QoL evaluation, suggest that improvement of menopausal symptoms and depressive mood may be independent of the life performance in those patients. However, longer treatment of a larger group of menopausal women with Melbrosia is necessary to accurately evaluate the effects of this product as manifested by the Frankfurt Self-concept Scale. There is no doubt that for relief of moderate to severe menopause symptoms, estrogen-containing preparations are the best option. However, for mild symptoms, the current recommendation is to advise lifestyle measures first, perhaps with dietary supplements containing isoflavones, black cohosh, or vitamin E.[37] Our study showed that menopausal symptoms are improved by Melbrosia, and if the results are confirmed in larger, controlled clinical trials, it may become a useful addition to our treatment armamentarium.

Because of the higher rates of coronary heart disease (CHD)-related morbidity and death and the higher prevalence of cardiovascular risk factors among elderly people, the attributable risk for any individual risk factor may be higher in the elderly than in younger adults.[38] Modification of risk factors in this older age group therefore may affect the morbidity and mortality from CHD. Low serum levels of HDL-cholesterol are among the risk factors that have been predictive of death from CHD among adults older than 70 years of age, particularly among women.[39] Therefore, interventions that target hypercholesterolemia may benefit older women. Treatment with Melbrosia caused a significant decrease in TC and LDL-cholesterol and a significant increase in HDL-cholesterol. Our data show similarities to previous trials reporting reduced LDL-cholesterol and TC levels with phytoestrogen treatment.[40,41] However, the exact mechanism of lipid level reductions remains unclear, and further studies are needed to confirm this pharmacologic action. The combination of phytoestrogens and bee products in Melbrosia also shares some similarities with oral HT in terms of its metabolic effects, namely elevation of TG levels.

Melbrosia nonsignificantly changed CRP and VCAM levels. In contrast to HT, for which lower CAM levels and elevated CRP levels are found in the short-term trials, the studied herbal medication did not significantly reduce serum VCAM-1 and caused no change in CRP during the first 3 months of therapy. This finding, however, must be confirmed in larger and longer-term randomized trials.

Summary

Our study demonstrated that 12 weeks of treatment with Melbrosia, a herbal medication containing bee products, leads to a significant improvement of menopausal symptoms and serum lipid levels. Our data support the use of this food supplement for treatment of menopausal symptoms. However, because of this study's uncontrolled open-label methodology, no cause-and-effect inferences can be drawn until a larger, longer-term, blinded, placebo-controlled, randomized trial is performed.