Influence of equol and resveratrol supplementation on health-related quality of life in menopausal women: A randomized, placebo-controlled study

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ContentslistsavailableatScienceDirect

Maturitas

j ourna l h o me pa g e :w w w . e l s e v i e r . c o m / l o c a t e / m a t u r i t a s

Inﬂuence

of

equol

and

resveratrol

supplementation

on

health-related

quality

of

life

in

menopausal

women:

A

randomized,

placebo-controlled

study

夽

Sergio

Davinelli

a,∗

_,

_Giovanni

_Scapagnini

a

_,

_Fulvio

_Marzatico

b

_,

_Vincenzo

_Nobile

c

_,

Nicola

Ferrara

d

_,

_Graziamaria

_Corbi

a

a_Department_of_Medicine_and_Health_Sciences_“V._Tiberio”,_University_of_Molise,_Campobasso,_Italy b_Department_of_Biology_and_{Biotechnology}_“L._{Spallanzani”,}_University_of_Pavia,_Pavia,_Italy c_Farcoderm_S.r.l.,_San_Martino_Siccomario,_Pavia,_Italy

d_Department_of_{Translational}_Medical_Sciences,_University_of_Naples_“Federico_II”,_Naples,_Italy

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received4August2016

Receivedinrevisedform26October2016 Accepted25November2016

Thispaperisdedicatedtothememoryof FulvioMarzaticopassedawayuntimelyon June5,2015. Keywords: Menopause Phytoestrogens Equol Resveratrol

a

b

s

t

r

a

c

t

Objective:Thisstudywasdesignedtoevaluatetheeffectsofequolandresveratrolsupplementationon

health-relatedqualityoflife(HRQoL)inotherwisehealthymenopausalwomenwithhotﬂashes,anxiety

anddepressivesymptoms.

Methods:Sixtyrecentlymenopausalwomenaged50–55yearswererandomizedina12-week,

placebo-controlledtrialtoreceive200mgoffermentedsoycontaining10mgofequoland25mgofresveratrol(1

tablet/day).TheprimaryoutcomewasthechangeinscoreontheMenopauseRatingScale(MRS),used

toevaluatetheseverityofage-/menopause-relatedcomplaints.Additionaloutcomemeasuresincluded

thesubject-reportedscoreontheHamiltonRatingScaleforDepression(HAM-D)andNottinghamHealth

Proﬁle(NHP),whichwasusedspeciﬁcallytoassesssleepquality.

Results:ThesymptomsassessedbytheMRSimprovedduringtreatmentintheactivegroup.Comparison

betweenplaceboandtreatmentgroupsrevealedstatisticallysigniﬁcantimprovementinparticularfor

drynessofvagina(−85.7%)(p<0.001),heartdiscomfort(−78.8%;p<0.001)andsexualproblems(−73.3%;

p<0.001).OntheHAM-Dsigniﬁcantimprovementsatweek12wereseeninworkandactivities(−94.1%)

(p<0.001).Subjectstreatedwithequolandresveratrolalsohadsigniﬁcantdifferencesinthesleepdomain

oftheNHP(p<0.001).

Conclusion:Theseﬁndingsprovideevidencethat12weeksofdietarysupplementationwithequoland

resveratrolmayimprovemenopause-relatedqualityoflifeinhealthywomen.

1. Introduction

Menopauseis characterizedbyfalling levelsofestrogenand

progesterone,lossofreproductivefunctionandpermanentendof

menstruation[1].Althoughsymptomsassociatedwithmenopause

vary widely, theymost often include hot ﬂashes, sleep

distur-bances, anxiety, and depression [2]. There are still no speciﬁc

and highly efﬁcient medical interventions to alleviate these

Abbreviations: HRT,hormonereplacementtherapy;ERs,estrogenreceptors; HRQoL,health-relatedqualityoflife;MRS,MenopauseRatingScale;HAM-D, Hamil-tonRatingScaleforDepression;NHP,NottinghamHealthProﬁle.

夽 TrialRegistration:ISRCTNregistryISRCTN10128742. ∗ Correspondingauthor.

E-mailaddress:sergio.davinelli@unimol.it(S.Davinelli).

symptoms and treat the clinical consequences of an

estrogen-deﬁcientstateassociatedwithmenopause.Forexample,despite

hormonereplacementtherapy(HRT)is thetreatmentofchoice,

itsusehasbeenlinkedtoanincreasedriskofdevelopingbreast

cancerandcardiovasculardiseases[3,4].Themodernperspective

toimprovemenopausalsymptomsandenhancethequalityoflife

may be theuse of plant-based therapies [5,6].In this context,

thereissubstantialevidencethatphytoestrogensandtheir

deriva-tiveshavethepotentialtoaddressseveralconditionsassociated

withmenopause[7].Phytoestrogensarepolyphenolicestrogenic

compounds of plant origin and classiﬁed in four main classes:

isoﬂavones, lignans,coumestans and stilbenes. Themetabolism

ofphytoestrogensin humansis complexandtheir

bioavailabil-ityislargelydeterminedbyintestinalmicroﬂora.Isoﬂavonesare

foundmainlyinsoy-basedfoodsandexhibitestrogenicactivityby

http://dx.doi.org/10.1016/j.maturitas.2016.11.016

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microﬂora.Equolhasastrongerestrogen-likeactivitythandaidzein

andthelackofclinicaleffectivenessofthismetaboliteinhuman

tri-alsmaydependonanindividual’sabilitytosynthesizeequolfrom

daidzein[9–11].Infact,theprevalenceofequol-producing

intesti-nalbacteriavariesfrom30%to50%inhumansandishigheramong

Asiansandvegetarians[12,13].Therefore,equolproductionisthe

keytoimprovethehealthbeneﬁtsofisoﬂavones.Soyandequol

supplementationmay bean appropriate nutritionalstrategy to

stimulateequolproductionalsoinnon–equolproducersand

ame-lioratesymptomsassociatedwithmenopause[14,15].Inaddition,

combinedformulationsofrationallyselectedphytoestrogensmay

haveagreaterpositiveimpactonthehealthofmenopausalwomen

[16].For example, it waspreviouslyshown that a combination

ofequolandresveratrolcanimproveperimenopausalsymptoms

inwomenandalsoincrease mitochondrialfunctionin

endothe-lialcells[17,18].Resveratrolisapolyphenolicphytoestrogenand

it hasa variety of potentially beneﬁcial effects, including

anti-inﬂammatory,immunomodulatory,andantioxidantproperties.As

aphytoestrogen,resveratrolhasbeenshowntobindthehumanER

withimplicationsforbreastcancerprevention.[19,20].Although

therearenohumanstudiesregardingtheeffectsofresveratrolon

menopausalsignsandsymptoms,arecenttrialdemonstratedthat

resveratrolmayenhancemoodandcognitioninpostmenopausal

women[21].Thisstudywasdesignedtoevaluatetheefﬁcacyofa

combineduseofequolandresveratrolonhealth-relatedqualityof

life(HRQoL)of60recentlymenopausalwomen.

2. Materialandmethods

2.1. Studydesign

Arandomized,double-blind,placebo-controlleddietary

inter-ventiontrialof12weeksdurationwasdesignedtoevaluatethe

effects of equol and resveratrol supplementation onHRQoL of

recently menopausal women. Of 90 eligible women, 25 were

excludedbecausenotmeetingtheinclusioncriteria,and5declined

toparticipate(Fig.1).Thus,atotalof60menopausalwomenwere

randomlyallocatedintotreatmentandcontrolgroupbasedona

restrictedrandomizationlistwithanallocationratioof1:1.Allthe

studyprocedureswerecarriedoutinaccordancewiththe

Declara-tionofHelsinki.Thestudyprotocolandtheinformedconsentform

wereapprovedbytheIndependentEthicalCommitteefor

Non-PharmacologicalClinicalTrialsonMarch30,2011(ref.no.2011/02)

andregisteredatISRCTNregistry(ISRCTN10128742).Allsubjects

providedwritteninformedconsentpriortotheinitiationofany

study-relatedprocedures.

2.2. Subjects

EligiblesubjectswerealladultCaucasianmenopausalfemales

agedbetween50and55yearsold.Theparticipantswereenrolled

(recruitmentandtreatment)betweenApril2011andJuly2011.The

inclusioncriteriawereasfollows:(1)nomenstrualcycleinthelast

12months;(2)20kg/m2_≥_BMI_<₂₅_kg/m2_;₍₃₎_case_history

char-acterizedbymenopausalcomplaintssuchashot ﬂush,anxiety,

emotionalinstability,sleepdisorders,anddepression;(4)

commit-menttomaintainsamedietaryhabitsduringthetrialperiod;(5)

commitmenttomaintainthenormaldailyroutine.Womenwere

ineligibleifanyof thefollowingcriteria werepresent:(1)case

historyrelatedtoendometrialhyperplasia;(2)HRT;(3)metabolic

facilitiesinSanMartinoSiccomario(PV),Italy.Subjectsattended

clinicvisitsatthetimeofrandomization(baseline)andat1and3

monthsaftertreatmentinitiation.

2.3. Randomization

Arestrictedrandomization listwascreatedusingPASS2008

(PASS, LLC. Kaysville, UT, USA) statistical software running on

WindowsServer2008R2StandardSP164bitEdition(Microsoft,

USA)byabiostatisticianandstoredinasafeplace.Randomization

sequencewasstratiﬁedusing10%maximumallowable%deviation

witha1:1allocationratio.Theallocationsequencewasconcealed

fromtheinsitestudydirectorinsequentiallynumbered,opaque,

andsealedenvelopes,reportingtheunblindedtreatment

alloca-tion(basedonsubjectentrynumberinthestudy).TheA4sheet

reportingtheunblindedtreatmentwasfoldedtorenderthe

enve-lopeimpermeabletointenselight.Afteracceptanceofthesubject

inthestudytheappropriatenumberedenvelopewasopened.An

independenttechniciandispensedeitheractiveorplacebo

prod-uctsaccordingtothecardinsidetheenvelope.Thestudyadhered

to established procedures to maintain separation between the

investigatoranditscollaboratorsandthestaffthatdeliveredthe

intervention.Investigatoranditscollaboratorswhoobtained

out-come measurements were not informed on theproduct group

assignment.Staffwhodeliveredtheinterventiondidnottake

out-comemeasurements.Subjects,investigatorandcollaboratorswere

keptmaskedtoproductsassignment.

2.4. Treatment

Theproductwasacommerciallyavailabledietarysupplement

(EquopausaD.Ulrich,PaladinPharmaS.p.A.,Turin,Italy)containing

200mgoffermentedsoy(including80mgofisoﬂavoneaglycones

and10mgofequol)and 25mgofresveratrolfromVitisvinifera.

Subjectswererandomlyassignedtoreceiveonceadaytheproduct

ortheplaceboina1:1ratio.Bothactiveandplaceboproductswere

intabletformandidenticalinappearance.Theywereprepacked

inblisters,andconsecutivelynumberedforeachsubjectaccording

totherandomizationlist.Subjects’compliancetotreatmentwas

assessedbymeansofproductaccountability,asfollows:ateach

visit,theexpectedamountofconsumedcapsuleswascompared

withtheamountdispensedminustheamountoftheproductthat

thesubjectreturned.

2.5. HRQoLmeasurements

Toevaluatetheefﬁcacyoftheintervention,weusedthe

val-idated HRQoL questionnaire Menopause Rating Scale (MRS) to

measuretheproportionofsubjectsachievinganimprovementin

menopausalsymptoms.TheMRSwasdevelopedandvalidatedto

evaluatetheseverityofmenopause-relatedcomplaints[22].A

5-point rating scale fromzero (no complaint)to four(extremely

severesymptoms)permitstodescribetheseverityofcomplaints

ofeachitem.TheMRSconsistsofelevenquestions,however,the

itemrelatedtoanxietywasnotincludedinthequestionnairesince

thissymptomwasassessedbyHamiltonRatingScalefor

Depres-sion(HAM-D).TheHAM-Disawell-knownclinicianstandardized

scaledesignedtomeasuredepressionseverity[23].Theoriginal

version of HAM-Dcontains 17 items. Eachitem is scored ona

scaleof0(notpresent)to4(severe),withatotalscorerangeof

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Fig.1.Flowdiagramofenrolment,interventionallocation,anddataanalysis.

severityand25–30moderatetosevere.Inthisstudy,emotional

dis-tressinmenopausalwomanwasassessedusing4itemsofHAM-D

pertainingtoworkandactivities,agitationandanxiety.Sleep

qual-itywasmeasuredusingtheNottinghamHealthProﬁle(NHP).The

NHPisaself-administeredquestionnaireconsistingof38itemsthat

detectshealthstatuschangesovertime.TheNHPisorganisedinto

sixdomains,includingemotionalreactions,energy,pain,physical

mobility,socialisolation,andsleep.TheNHPscoresrangefrom0

to100,withlowerscoresindicatinglowerlevelsofdistress[24].In

thepresentstudy,weusedthesleepsectionoftheNHPtoassess

differentaspectsofsleepdisturbancesassociatedwithmenopause.

2.6. Statisticalanalysis

Without information onthe menopausaleffect of theequol

andresveratrolsupplementation,asamplesizeof60patientswas

required.Thesamplesizecalculationwasbasedontheresultsof

menopausalsymptoms prevalenceand previoussimilarstudies

[25,26].Settingupanalphavalueat0.05withaconﬁdencelevelof

90%,andconsideringaprevalenceofmenopausalsymptomsof60%

andapossibleresponsedistributionof5%,arecommendedsample

sizewasof26foreachgroup.Theanticipatedeffectofthe

treat-mentwasobtainedbyapreviousstudy[27],andwiththisnumber

ofparticipants,wewereabletodetectdifferencesinmenopause

symptomscoresfrom baseline toweek12 betweenactive and

placebogroups.StatisticalanalysiswasperformedusingNCSS2008

(NCSS,Kaysville,UT,USA).Theresultsofthequestionnairewere

reportedasmeans±StandardError(SE)orpercentagevalues.Data

expressedaspercentagesshowthesubjectswiththemenopausal

complaints.Thesepercentageswerecalculatedonthenumberof

subjectsthatattheenrolmentscoredthesymptomhigherthan

“none”.Subjectsscoringthesymptom“absent”wereexcludedfrom

theanalysis.Intragroup(vs.baseline)andintergroup(activevs.

placebo)statisticalanalysiswascarriedoutusingamixedeffect

model.Ap-value<0.05wasconsideredstatisticallysigniﬁcant.

3. Results

No majordeviationwasobservedin thetreatmentregimen.

Allsubjectswereincludedinthesafetyanalysisdataset.In

gen-eral, the treatment was well tolerated and no adverse events

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Sex(F/M)%(n) 100/0(30) 100/0(30) ns

MenopauseRatingScale(Grading)

Hotﬂushes,sweating(Moderate) 3.2±0.2(100%) 3.1±0.1(100%) ns

Heartdiscomfort(Mild) 1.8±0.1(63.3%) 1.9±0.1(66.7%) ns

Sleepproblems(Moderate) 3.1±0.1(100%) 3.0±0.2(100%) ns

Depressivesymptoms(Mild) 2.0±0.1(66.7%) 2.0±0.1(66.7%) ns

Irritability(Mild) 2.5±0.2(76.7%) 2.5±0.2(83.3%) ns

Physicalandmentalexhaustion(Moderate) 2.5±0.1(86.7%) 2.4±0.1(83.3%) ns

Sexualproblems(Moderate) 2.8±0.1(100%) 2.8±0.1(100%) ns

Bladderproblems(Mild) 2.1±0.2(66.7%) 2.1±0.1(83.3%) ns

Drynessofvagina(Moderate) 2.7±0.1(93.3%) 2.6±0.1(93.3%) ns

Jointandmusculardiscomfort(Moderate) 3.0±0.2(90%) 2.9±0.2(93.3%) ns

HamiltonRatingScaleforDepression(Grading)

Workandactivities(Lossofinterestinactivity) 2.1±0.2(56.7%) 2.0±0.1(60.0%) ns

Agitation(Fidgetiness) 1.4±0.1(70.0%) 1.5±0.1(66.7%) ns

Anxiety(psychological)(Subjectivetensionandirritability) 1.4±0.2(63.3%) 1.4±0.1(63.3%) ns

Anxiety(somatic)(Moderate) 1.8±0.2(63.3%) 1.7±0.1(60.0%) ns

NottinghamHealthProﬁle

Takepillstohelpmesleep 43.3% 40.0% ns

I’mwakingupintheearlyhoursofthemorning 63.3% 60.0% ns

Ilieawakeformostofthenight 20.0% 23.3% ns

Ittakesmealongtimetogettosleep 40.0% 40.0% ns

Isleepbadlyatnight 63.3% 60.0% ns

Dataareexpressedasmean±SD(%).F,female;M,male.

Table2

PercentageofsubjectsreportingsymptomsontheMRSinthetwogroups,atbaseline,andafter1and3monthsoftreatment.

Symptoms(%) ACTIVE(%) PLACEBO(%)

T0 T1 T3 T0 T1 T3

Hotﬂushes,sweating(Moderate) 100 46.7 26.7*** 100 76.7 80.0§

Heartdiscomfort(Mild) 63.3 23.3** 13.4*** 66.7 43.4 36.7§§§

Sleepproblems(Moderate) 100 63.3 46.7* 100 66.7 83.3§§

Depressivesymptoms(Mild) 66.7 66.7 16.7** 66.7 66.7 43.4§

Irritability(Mild) 76.7 43.3 30.0* 83.3 56.6 56.6§

Physicalandmentalexhaustion(Moderate) 86.7 63.4 30.0** 83.3 86.6 60.0§§

Sexualproblems(Moderate) 100 76.7 26.7*** 100 80.0 97.7§§

Bladderproblems(Mild) 66.7 33.4 13.3** 83.3 76.6 63.3§

Drynessofvagina(Moderate) 93.3 76.6 13,3*** 93.3 89.9 89.9§§§

Jointandmusculardiscomfort(Moderate) 90.0 30.0* 16.7** 93.3 73.3 73.3§§§

Intragroupanalysisvsbaseline:*p<0.05;**p<0.01;***p<0.001;Intergroupanalysisatthesametime:§p<0.05;§§p<0.01;§§§p<0.001.

Table3

PercentageofsubjectsreportingdepressivesymptomsinthetwogroupsandmeasuredbyHAM-Datbaselineandafter1and3monthsoftreatment.

Symptoms ACTIVE(%) PLACEBO(%)

T0 T1 T3 T0 T1 T3

Workandactivities(Lossofinterestinactivity) 56.7 13.3*** 3.3*** 60.0 40.0 36.7§§§

Agitation(Fidgetiness) 70.0 19 33.3* 66.7 54 47.6§

Anxiety(psychological)(Subjectivetensionandirritability) 63.3 43.3 20*** 63.3 53.8 50.6§§

Anxiety(somatic)(Moderate) 63.3 43.3 23.3*** 60.0 48.6 45.7§

Intragroupanalysisvsbaseline:*p<0.05;**p<0.01;***p<0.001;Intergroupanalysisatthesametime:§p<0.05;§§p<0.01;§§§p<0.001.

Table4

PercentageofsubjectsreportingsleepdisordersinthetwogroupsandassessedbyNHPatbaselineandafter1and3monthsoftreatment.

Symptoms ACTIVE(%) PLACEBO(%)

T0 T1 T3 T0 T1 T3

Takepillstohelpmesleep 43.3 40.0 23.3* 40.0 40.0 36.7§

I’mwakingupintheearlyhoursofthemorning 63.3 49.9 30.0*** 60.0 60.0 53.3§§§

Ilieawakeformostofthenight 20.0 16.7 3.3* 23.3 20.0 20.0§

Ittakesmealongtimetogettosleep 40.0 36,7 16.7*** 40.0 36.7 34.3§

Isleepbadlyatnight 63.3 40.0* 23.3*** 60.0 56.6 46.7*§§§

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characteristics(Table1)weresimilaracrosstreatmentarms,

indi-catinganunbiasedrandomizationandtheabsenceofcovariates.

Nosigniﬁcantdifferenceswereobservedbetweenthetwogroups

(activeandplacebo)regardingage,ageatmenopause,andtime

since menopause, as well as weight or BMI. The early

symp-tomsevaluatedbyMRS,HAM-D,andNHPwerealsohomogeneous

betweenthetwogroupsandnostatisticallysigniﬁcantdifferences

(p>0.05)atbaselinewereobserved.Comparedwiththeplacebo

group,theactivegroupshowedanimprovement ineachofthe

itemsincludedinthestudy.Astatisticallysigniﬁcantimprovement

wasfoundinallthesymptomsassessedbyMRS.Inparticular,the

bestresultswereregisteredinthereductionofsubjectsaffectedby

drynessofvagina(−85.7%;p<0.001),heartdiscomfort(−78.8%;

p<0.001)andsexualproblems(−73.3%;p<0.001).The

improve-mentwassigniﬁcantnotonlycomparedtothepreviousevaluation

ofthesamegroupbutalsorespecttotheplacebogroup(Table2).

Moreover,thetreatmentwasabletosigniﬁcantlyreducethe

num-ber of subjects affected by depressive symptoms evaluated by

HAM-D(Table3).Inparticular,thenumberofsubjectsaffectedby

lossofinterestinperformingworkactivitieswasreducedby94.1%

at3monthsoftreatment,andincomparisontotheplaceboatthe

sametime(p<0.001).TheanalysisoftheNHPshowedasigniﬁcant

improvementinthesub-items“sleep”forallthesubjects

under-gonetotheactivetreatmentcomparedtotheplacebogroupand

overthetime,especiallyinthequalityofsleep(p<0.001)(Table4).

4. Discussion

Combinedadministrationofphytoestrogensorindividual

phy-toestrogentreatmentswereassociatedwithimprovementinsome

menopause-relatedsymptoms,includingreductionsinhotﬂashes

and vaginaldryness [28]. Thepresent studyexaminedwhether

supplementationwithequolandresveratrolcanreducethe

sever-ityofmenopausalsymptomsinrecentlypostmenopausalwomen.

Toourknowledge,thisistheﬁrsthumanstudyspeciﬁcally

con-ducted toinvestigatetheeffectiveness ofequol and resveratrol

onHRQoLinhealthymenopausalwomen.Theproposedlevelof

equolintake(10mg)hasbeenusedinseveralclinicaltrialsand

is reported to be effective for menopausal symptoms, without

anyseriousadverseevents[29,30].Interms ofsafety,concerns

havebeenexpressedaboutthepossibleadverseeffectsof

phytoe-strogensbecausetheirafﬁnityfortheERs.Theseconcernshave

focusedprimarilyonestrogen-sensitive tissues,particularlythe

breastandendometrium.However,recentclinicalstudies

involv-ing menopausalwomen have not shown an increase in breast

cancerriskorincreaseinendometrialhyperplasiafollowingequol

treatment[30–34].Themostcommonadverseeventsassociated

withresveratrolsupplementationismild diarrheaandreported

inarecentpilotclinicalstudyinvolvingpostmenopausalwomen

withhighBMIwhoconsumed1g/dayofresveratrolfor12weeks

[35]. Althoughtheproduction ofequol inhumans is solelythe

result of theintestinal bacterialmetabolism of daidzein, it has

beenshownthatequolsupplementationmayrelievemenopausal

symptomsandimprovemoodstates[33].Inaddition,resveratrol

hasbeenreportedtoact asa phytoestrogen and arecent

clin-ical studydemonstrated that resveratrolhas favourable effects

on estrogen metabolism and circulating sex steroid hormones

[29,35].Thus, it is conceivablethat thesynergistic multi-target

effectofthesetwocompoundsmayofferanon-pharmaceutical

approachfor managingmenopause-relatedsymptoms.Overthe

lasttenyears,synergyassessmenthasbecomeakeyareain

phy-tomedicineresearch.Anemergingtherapeuticapproachinvolves

the combination of distinct phytochemicals to enhance

treat-ment efﬁcacyand improve clinicalresponse [36]. A largebody

of evidence hasrevealed that mixtures of polyphenols maybe

validforthemanagementofmultifactorialage-relateddiseases.

Thesemixturesworkinasynergisticmanner,andspecial

combi-nationsareexceptionallyeffective.Polyphenolshavepleiotropic

effects able toaffect and modulatemultipleprocesses, suchas

signalling and energy-sensitive pathways, oxidative stress and

inﬂammation-relatedprocesses,mitochondrialfunctionality,

epi-genetic machinery, and histone acetylation [37]. There are no

clinicaltrialsevaluatingcombinationsofcompoundsusedinthis

study,buttheindividualphytoestrogensusedinthissupplement

havebeenpreviouslyevaluated.Apilotstudydemonstratedthat

10mg/dayofequoliseffectiveforrelievingmuscleandjointpain

inpostmenopausalwomen[38].Similarly,a12-weekdouble-blind

placebo-controlled trial showed beneﬁcial effects of 10mg/day

of equol on major menopausal symptoms, including neck or

shouldermusclestiffness,inequolnonproducingpostmenopausal

Japanesewomen[32].Ishiwataetal.alsodemonstratedthat10mg

ofequol consumedthreetimesperdayimprovesmood-related

symptomsinperimenopausal/postmenopausalequol

nonproduc-ers[33].Recently,adietaryinterventiontrialevaluatedtheeffects

ofresveratrolsupplementation(75mgtwicedaily)ongeneralwell

beinginpostmenopausalwomen.After14weeksof

supplemen-tation,resveratrolhastheabilitytoenhancemoodandcognitive

performance,probablyduetoitspotentvasoactiveproperties[21].

In ourrandomized,placebo-controlled study,wefoundthat 12

weeks of supplementation with equol and resveratrol is

effec-tivetocounteractclimactericcomplaintsgenerallyassociatedwith

anincreasedprevalenceofpoorqualityoflife.Itisnotablethat

theblendofphytoestrogenstestedinourstudyproduced

simi-lar orgreaterreductionsonmenopausalsymptoms,assomeof

theaforementionedstudies.Moreover,it isreasonable to

spec-ulatethatthemagnitude ofbeneﬁtobserved inthis studymay

result froma combination of ingredients versusthe useof the

individualcompounds.Theassessmenttoolsthatweusedinour

studywerebasedonmodiﬁedMRS,HAM-D,andNHP.These

self-administratedquestionnaireshavebeenvalidatedandtranslated

inmanylanguagesandusedinseveralclinicalstudies

investigat-ingtheseverityof menopausalsymptoms.Analysisof theMRS

scoreshowedthatthesupplementationofequolandresveratrol

waseffectiveinimprovingHRQoL.Inparticular,themost

signif-icant improvement inreducing menopausalsymptoms wasthe

reduction of subjects affected by dryness of vagina, heart

dis-comfortandsexualproblems.Participantsshowedalsosigniﬁcant

improvementsfrombaselineto3monthsoftreatmentonallitems

evaluatedbyMRS.Giventhenumberofpostmenopausalwomen

whoexperiencedepression,weusedamodiﬁedHAM-Dtomeasure

depressivesymptoms.Bachneretal.arguedthatshortenedformats

of HAM-Darewidelyused toevaluatepsychometricproperties

becausetheseabridgedversionsare moresensitivetomeasure

symptomlevelsand patientsin remissions[39].Analysisof the

treatmenteffect onchange in theHAM-D items (loss of

inter-est in activity, anxiety/somatic, anxiety/psychological) revealed

an advantagefor equol and resveratrolwithinwork and

activ-itiesitem. Interestingly,wefounda signiﬁcantimprovementat

3monthsfrombaselinein reducinganxietyandlossofinterest

in activity. Due to thehigh co-occurrence of depression,

anxi-etyandmenopausecomplaintsinthepostmenopausalpopulation,

thisﬁndingisparticularlyimportantbecausethereisapaucityof

humanstudieswithphytoestrogensthataddresstheseaspectsin

themenopausemanagement.SleepdisorderscandecreaseHRQoL,

leading to anxietyand depression in menopausal women [40].

Sleepdisturbanceswereassessedbyusingthe5-itemsleep

dimen-sionoftheNHP,avalidatedandwidelyusedmethodofassessing

qualityoflife[41].Moreover,severalstudiesemphasizedthe

reli-abilityofNHPscaletomeasureHRQoL,anditcouldbealsoused

tomeasuresleepqualityinpostmenopausalwomen[42,43].The

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theretentionrate was100%for 3 monthsof intervention.This

maybeduetomultiplefactors:(1)participantsreceivedweekly

callsfromstaffmembers;(2)thestudyhasnotrequiredsigniﬁcant

amountofeducation/trainingorgreatamountoftimeinvestment;

(3)thedeliveryform(oral,1tablet/day)allowedhighcompliance

andconsequenthighretentionrate.However,ourstudyhasa

num-beroflimitations.Firstly,oneofthemajorlimitationswasthesmall

samplesize.Secondly,seriousadverseeventswerenotassessedto

evaluatetherelationshipbetweenphytoestrogenintakeandbreast

orendometrial cancerrisk.Lastly, ourstudydidnotdetermine

whethertheenrolledsubjectswereequolproducers.Therefore,

eventhoughthemajority ofWesternwoman isnot equol

pro-ducer,wedidnotstratifytreatmentandplacebogroups onthe

basisofequol-producingstatus.Theinterventionperiodwith

phy-toestrogensthatwouldelicitabeneﬁcialresponseinmenopausal

womeniscontroversialandusuallyrangesbetweenfrom3to12

months[44].Although12weeksoftreatmentwasableto

signiﬁ-cantlyreducethemostprevalentmenopausalsymptoms,another

potentiallimitationofourstudywasarelativelyshort-term

treat-ment.Furthermore,wedidnotperformafollow-upaftertheendof

treatmentandourstudyprovidesnoinsightintothemechanismof

beneﬁt.Theseresultsmustbeconsideredaspreliminaryandwill

requireconﬁrmationinalargertrial.Nevertheless,theseﬁndings

canbeconsideredreliableaccordingtotheaimofthestudy.

5. Conclusion

Inconclusion,thepresentstudyprovidesevidenceinsupport

ofthehypothesis thata combinationofphytoestrogenshasthe

potentialofasafeandeffectiveapproachforreducingmenopausal

symptoms.Speciﬁcally,wehaveshownthata12-week

interven-tionwithequolandresveratrolisbeneﬁcialforHRQoLpromotion

inrecentlymenopausalwomen.Replicationofthestudyinlarger

cohortswithmultipleHRQoLassessmentsisnecessary.

Contributors

SDwasresponsibleforstudydesign,dataanalysis,data

inter-pretation,andmanuscriptpreparation.

GSwasresponsiblefor studydesign,datainterpretationand

manuscriptpreparation.

FMwasresponsiblefordatacollection.

VNwasresponsiblefordatacollectionanddatainterpretation.

NF was responsible for data interpretation and manuscript

preparation.

GCwasresponsiblefordataanalysis,datainterpretationand

manuscriptpreparation.

Allauthorssawandapprovedtheﬁnalversion.

Conﬂictofinterest

Theauthorshavenoﬁnancialorothercompetinginterestto

declare.

Funding

Thisstudywasnotsupportedbyanyindustrialfunds.Paladin

Pharma S.p.A. only provided the placebo and the active

treat-ment.Thiscompanyhadnoinﬂuenceonthestudydesign;inthe

The study protocol and the informed consent form were

approved by the Independent Ethical Committee for

Non-PharmacologicalClinicalTrialson30March2011(ref.no.2011/02)

andregisteredatISRCTNregistry(ISRCTN10128742).Allsubjects

providedwritteninformedconsentpriortotheinitiationofany

study-relatedprocedures.

Provenanceandpeerreview

Thisarticlehasundergonepeerreview.

AppendixA. Supplementarydata

Supplementarydataassociatedwiththisarticlecanbefound,in

theonlineversion,athttp://dx.doi.org/10.1016/j.maturitas.2016.

11.016.

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