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The Effects of Flaxseed on Menopausal Symptoms and Quality of Life

Article  in  Holistic nursing practice · May 2015

DOI: 10.1097/HNP.0000000000000085 · Source: PubMed

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 F E AT U R E S

The Effects of Flaxseed on Menopausal

Symptoms and Quality of Life
■ Nuray Egelioglu Cetisli, PhD, RN ■ A. Saruhan, PhD, RN ■ B. Kivcak, PhD

The purpose of this study was to analyze the effects of flaxseed on menopausal symptoms and quality of life
throughout the menopausal period. The empirical research was conducted in an obstetrics and gynecology
outpatient department of a university hospital and involved 140 menopausal women who were divided into
4 groups. The menopausal symptoms decreased and the quality of life increased among the women who used
flaxseed for 3 months. KEY WORDS: flaxseed, menopause, menopausal symptoms, nurses, nursing, quality of life
Holist Nurs Pract 2015;29(3):151–157

Menopause is natural and physiological for women;
it is not a disease. However, it is a period that can
negatively affect the quality of a woman’s life because
of the intensity and length of the symptoms and
potential risks and pathologies. Herbal estrogens taken
in the diet increase the estrogen level that decreases
during the menopausal period, and their estrogenic
properties can avert menopausal symptoms. Because
of its estrogenic, antiestrogenic, antioxidant, and
antiproliferative properties, a diet of phytoestrogenic
herbs can decrease the frequency of vasomotor
symptoms by increasing the estrogen level and
changing the hormonal balance.1-5 Phytoestrogenic
agents are chemicals that can act as a natural estrogen
in the human body. There is no synthesis or deposit of
these compounds in the body, and their only source is
an intensive herbal diet containing these compounds.
Phytoestrogens can be found in grains, vegetables, and
fruits. The most well-known and enriched sources of
phytoestrogens are flaxseed and soy. Phytoestrogens,
such as flaxseed and soy, have been shown to affect
menopausal symptoms within 12 weeks.6-9
Author Affiliations: Department of Obstetric and Gynecologic Nursing,
Faculty of Health Sciences, Izmir Katip Celebi University, Izmir, Turkey
(Cetisli); and Faculty of Nursing (Saruhan), and Faculty of Pharmacy
(Kivcak) Ege University, Izmir, Turkey.
The authors have disclosed that they have no significant relationships with,
or financial interest in, any commercial companies pertaining to this article.
Correspondence: Nuray Egelioglu Cetisli, PhD, RN, Obstetric and
Gynecologic, Faculty of Health Science, Izmir Katip Celebi University,
Cigli 35620, Izmir, Turkey (nurayegelioglu@gmail.com).
DOI: 10.1097/HNP.0000000000000085
Intensive observation, support, care, and health
training are needed during menopause. To increase the
quality of life in terms of physical, mental, and social
lives, women need to know the potential health
problems that might arise during menopause in order
to take proper precautions. Women need support,
consultation, and information about menopause.
Because they have important roles in increasing the
quality of the lives of women, the general goals of
menopausal care nurses are to ensure that women and
their families understand that menopause is a natural
period of a life. These nurses are key people for
enabling women to cope with social, physical, and
emotional problems. Informing women and their
families about menopause, correcting misunderstood
beliefs and perceptions, and planning the sexual lives,
aliments, practices, and social activities of the women
are also other roles of the nurses. Nurses who study
women’s health should be the main group that
provides complementary methods to cope with
menopausal symptoms due to their scientific
knowledge about the protection, development, and
sustainment of the health of menopausal women.10,11
The number of studies in the literature related to the
efficacy of training and complementary treatment
methods for decreasing menopausal symptoms to
affect the quality of life is very limited. Brzezinski
et al12 sought to determine the effects of a diet heavy
in phytoestrogen on the menopausal complaints of
women in the climacteric period. In this study, these
authors provided a diet heavy in phytoestrogen to an
experimental group (n = 78) over 12 weeks while not
performing any manipulations in the control group

151

Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
152 HOLISTIC NURSING PRACTICE • MAY/JUNE 2015
(n = 36). At the end of 3 months, the complaints of
the women in the phytoestrogen group related to
symptoms such as hot flashes, vaginal dryness, and
menopausal symptoms were significantly decreased
compared with their pretreatment scores, whereas the
differences in the control group were not significant.12
In a random controlled study by Lewis et al,13 the
effects of soy flour and flaxseed on the quality of life
and the frequency and strength of hot flashes in
women in the postmenopausal period who ate biscuits
containing wheat flour were reviewed. In this study,
flaxseed was given to 28 women and soy flour was
given to 31 women. The biscuits were given for
4 months, and the authors found that the strength of
the hot flashes of the group that was given biscuits
containing flaxseed was weaker than that of the group
that was given biscuits containing wheat flour.13
Studies of the efficacy of training and
complementary treatment methods that can be used to
decrease the effects of menopausal symptoms on
quality of life are notably limited. This study was
undertaken to determine the effects of using flaxseed
and training throughout the menopausal period on
women’s menopausal symptoms and quality of life.
METHODS
Sample and design
This study was planned to analyze the differences of
in the quality of life and experiences of menopausal
symptoms between women who used flaxseed and
received training and hormone replacement therapy
(HRT) and a control group. This experimental
research was planned to be composed of pretests,
posttests, and a control group.
The research was conducted with participants who
were being treated in the obstetrics and gynecology
outpatient department of a university hospital and had
provided consent to participate in the study. Women
who had experienced their last menstrual bleeding at
least 1 year before (ie, diagnosed as menopausal), had
not received hormone treatment in the last year, and
who had not used vitamins, minerals, or phytoestrogens
were accepted into the study. Women with a diagnosis
of surgical menopause, diabetes, hypertension,
cancer, hypo/hyperthyroidism, hyperlipidemia,
or gastrointestinal system disease and those who did
not want to participate were excluded from the study.7
The study was conducted with 140 women. Seventy
women were in the experimental groups (experimental
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
group 1 and experimental group 2), 35 women were in
the experimental variable group, and 35 women were
in the control group. Using the data obtained from the
study, a power analysis was completed with the
Minitab statistical software, and the test results of this
study were found to be 99% powerful. The groups
were homogenized in terms of the women’s age,
length of menopause, and frequency of menopause
symptoms.
In the design of the study, an expert advised
regarding the issue of securing the patients. Only flax
seed that was analyzed in terms of its content and
certified as dependable were used. The study included
a provision to remove any participants from their
group if any anomalies were observed in their
biochemical or anthropometric test results at the end
of the first month. However, no variations were
observed in the anthropometric or biochemical test
results, and all participants completed the study.
The women who participated in the study were
categorized into 2 groups according their quality of
life and menopausal symptoms.
Experimental group: This group had 2 subgroups.
Experimental group 1: Thirty-five women who did not
receive HRT or for whom HRT was contraindicated
were included in this group. This group received 5 g
of flaxseed daily.
Experimental group 2: This group was identical to ex-
perimental group 1, with the exception of the training
that was given to the participants
The participants in both groups were asked to
complete a patient assessment questionnaire by
answering questions from a Menopause Rating Scale
and the SF-36 Quality-of-Life Scale at the first visit.
Doses for 1 month (150 g) were given to all
participants in the experimental groups, and they were
asked to use 5 g per day. To control for the possible
side effects of flaxseed, anthropometric and
biochemical tests were performed at the first and
second (after 1 month of flaxseed use) visits. The
doses for the second month (300 g) were given to the
participants whose test results were normal at the
second visit. At the final visit, the participants were
asked to answer the questions from the Menopause
Rating Scale and the SF-36 Quality-of-Life Scale. The
women were given detailed instructions regarding how
to use and store flaxseed. Furthermore, a brochure that
was prepared by the researcher was given to the
participants.
 Effects of Flaxseed on Menopausal Symptoms and Quality of Life
Training and an informative booklet about
menopause, its symptoms and treatments, and
techniques for coping with menopause were given after
the first visit to the participants in experimental group
2 but not to the participants in experimental group 1.
The participants in the study were telephoned (every
15 days) to inquire whether they had any problems
using the flaxseed. Moreover, the researcher provided
her phone number to the participants with instructions
to call her if they had any problem using the flaxseed.
Experimental variable group
This group consisted of 35 women who had begun
HRT or were approved for HRT by the doctor in the
gynecology policlinic of a university hospital
(typically, drug treatment with 2 mg of estradiol
hemihydrate + 1 mg of norethindrone acetate was
given). At the first visit, the participants were asked to
complete a patient assessment form that includes
questions about sociodemographic data and questions
from a Menopause Rating Scale and the SF-36
Quality-of-Life Scale. At the final visit, all
measurements were repeated.
Control group
This group consisted of 35 women who did not
receive any medical or complementary treatment. The
participants in this group were asked to complete a
patient assessment form that included questions about
sociodemographic data and questions from the
Menopause Rating Scale and the SF-36
Quality-of-Life Scale. At the final visit, all of the
measurements were repeated.
Instruments
Patient assessment form
This form had 8 questions that were used to collect
data about the women who participated in the research.
These data were age, education, profession, data about
menopause (age and length of menopause, complaints
about menopause, and when those complaints began
and their frequency), blood pressure anthropometric
data (ie, weight, height, body mass index, waist size,
hip size, and waist/hip ratio), and biochemical values
(ie, fasting blood glucose, total triglycerides, total
cholesterol, low-density lipoprotein, high-density
lipoprotein, very high-density lipoprotein, aspartate
aminotransferase, and alanine aminotransferase). The
form was prepared by the researcher after examining
the reference literature and similar studies.3,6,7,14
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153
Menopause Rating Scale
This scale was first developed in German in 1992 by
Schneider et al to measure the strength of menopausal
symptoms and their effects on quality of life and was
subsequently adapted to English in 1996 and tested for
validity and reliability. Both validity and reliability for
the Turkish version were tested by Can Gurkan in
2005, who reported a Cronbach α value of 0.84.15 In
the present study, the Cronbach α value was 0.82.
Eleven items evaluating menopausal complaints
were rated on a Likert-type scale with the following 4
options: 0, none; 1, weak; 2, medium; 3, strong; and 4,
very strong. Scores were given for each item, and the
total score of the scale was calculated. There was no
cutoff point for the scale. The minimum score was 0,
and the maximum score was 44. The results were
categorized as follows: weak, 0-11; medium, 12-23;
strong, 24-33; and very strong, 34-44. Higher scores
indicated stronger complaints.
The scale has 11 items related to menopausal
complaints in the following 3 subdivisions:
1) Somatic complaints: These included items related
to hot flashes (sweating attacks), cardiac diseases,
sleeping problems, and joint and muscle
complaints.
2) Psychological complaints: These included items
such as dispiritedness, nervous derangement,
apprehension, and physical and mental fatigue.
3) Urogenital complaints: These included sexual
problems (changes in sensuality, sexual
intercourse, and satisfaction), urinary problems
(difficulty urinating, frequent urinating), and
vaginal problems.15
SF-36 Quality-of-Life Scale
This scale was developed by Ware in 1987 to
analyze the quality of life in terms of health and to
measure the general results of treatment independently
of age, illness, and treatment. Validation and
reliability tests of this scale were performed in Turkey
by Pınar in 2005, and scale’s reliability coefficient for
repeated testing is 0.94 and the Cronbach α value,
which defines the structural coherence, is 0.92.16
The SF-36 Quality-of-Life Scale is composed of 36
questions and 8 subscales. The second question of the
scale is related to the perception of changes in health
in the previous 12 months, and the other questions
evaluate the previous 4 months. The Physical and
Mental Health score is calculated by summing the
weighted scores of the questions involving the
154 HOLISTIC NURSING PRACTICE • MAY/JUNE 2015
subscales of SF-36 Quality-of-Life Scale. There is no
total score calculation. The calculated scores and
subscale scores are expressed as continuous variables
that range between 0 and 100. “Zero” indicates
unhealthy, whereas “100” indicates good health. There
is no intersection point of the scale. The aim of
calculating the score is to ease comparison and
interpretation.16
Physical functionality, physical roles, and pain are
assessed in the calculation of the physical health
score, whereas mental roles and mental functionality
are assessed in the calculation of the mental health
score. The overall health perception, vitality, and
social functionality supplement both scores in the
same manner. The second question was not included
in the evaluation because it is related to changes in
health perception in the previous 12 months.16
Flaxseed education brochure
The researcher prepared a literature-referenced
brochure for the women who used the flaxseed in the
experimental groups (ie, experimental groups 1 and 2)
to inform the participants about the ingredients of
flaxseed, its benefits, usage, side effects, and points of
caution related to its use.1-3,6,9,17
Menopause education brochure
The researcher prepared a literature-referenced
brochure for the women in experimental group 2 that
informed them about menopause, common symptoms,
diagnosis and treatment methods, digestion, sexuality,
and techniques for coping with menopause.10,11,17
The researcher abstained from using medical
terminology while preparing the brochure, and the
opinions of 10 experts were sought out. Revisions
were performed on the basis of the experts’
evaluations. The revised brochure was then given to 10
women to determine the clarity of the final brochure,
and feedback was acquired. These 10 women did not
participate in the study.
Ethical considerations
Before the data were collected, the study was
approved by the institutional review board of the study
site, which was a university hospital in Turkey. The
researcher explained the aim of the study to
participants, and their written consent was obtained
prior to the study.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Statistical analysis
The survey forms used in the study were first
examined by the researcher for the presence of errors,
and the data were then entered and processed using a
computer. The data analyses were performed with the
SPSS 11.00 software. Chi-square homogeneity tests
were applied to the women’s demographic
characteristics (ie, age, menopausal period, and the
frequency of menopausal symptoms). One-way
analyses of variance were used to analyze the
women’s SF-36 Quality-of-Life Scale score averages
and Menopause Rating Scale score averages for the
first and final visits. Variance analysis was performed
with repeated measurements to analyze the variation
in the scale scores average between the visits. Tukey
(HSD) tests and correlation analyses were used to
determine the relationships between the average SF-36
Quality-of-Life Scale scores and the women’s
Menopause Rating Scale scores.
FINDINGS
All 4experimental groups were found to be
homogeneous; no significant differences were found
(P > .05) between the groups in terms of the women’s
average ages, average ages of menopause, or average
menopause periods (Table 1).
Regarding the visits, the difference between the
Menopause Rating Scale total score averages was
statistically significant (Wilks λ = 0.84, P < .05). The
strength of menopause symptoms that the women
experienced decreased between the first and the last
visits in experimental group 1, group 2, and the
experimental variable group. The decreases were 8.7%
in experimental group 1, 9.8% in experimental group
2, and 10% in the experimental group variable. The
strength of menopausal symptoms experienced by
the women in control group increased by 6.9%, and
the difference in the average scores was statistically
significant (Table 2).
Regarding the visits, the differences between SF-36
Quality-of-Life Scale Physical and Mental Health
score averages were statistically significant (Wilks
λ = 0.70, P < .05; Wilks λ = 0.92, P < .05). The
SF-36 Quality-of-Life Scale Physical and Mental
Health score averages seemed to be similar to those of
the first visit, whereas at the last visits of experimental
group 1 (who were given flaxseed for 3 months) and
experimental group 2 (who were given information
 Effects of Flaxseed on Menopausal Symptoms and Quality of Life 155

TABLE 1. Characteristics of the Subjects

Experimental Experimental Experimental Variable Control Group,
Characteristics Group 1, X ± SD Group 2, X ± SD Group, X ± SD X ± SD

Age average 47.88 ± 2.63 47.91 ± 2.44 47.80 ± 2.69 47.37 ± 2.83
F = 0.69; P = .74
Age of menopause average, y 47.25 ± 2.45 47.37 ± 2.19 46.85 ± 2.86 46.62 ± 2.93
F = 0.36; P = .96
Menopause period average, mo 6.80 ± 4.02 6.85 ± 3.55 6.68 ± 3.87 6.88 ± 3.94
F = 0.29; P = .91

TABLE 2. Total Score Averages on the Menopause Rating Scale for the Women According to Visit
Menopause Rating Scale Total Score Average
Monitors Experimental Group 1 Experimental Group 2 Experimental Variable Group Control Group

First monitor 18.71 ± 7.02 21.00 ± 5.31 21.54 ± 5.22 18.88 ± 7.50
Last Monitor 14.88 ± 4.78 16.71 ± 4.01 17.14 ± 6.17 22.85 ± 5.85
Wilks λ = 0.84; P = .00
Change, % −8.7 −9.8 −10.0 +6.9

about menopause after the first visit and given DISCUSSION

flaxseed for 3 months), the Physical and Mental
Health score averages for the SF-36 Quality-of-Life
Scale increased. In the experimental variable group
(given HRT for 3 months), the Physical Health score
average decreased whereas the Mental Health score
average increased. In the control group to which none
of the treatments were applied, both the Physical and
Mental Health score averages decreased
(Table 3).
Across all groups, a weak negative relation was
observed (P < .05) between the total average score on
the Menopause Rating Scale and the Physical Health
average score of the SF-36 Quality-of-Life Scale.
Regarding these results, the women’s SF-36
Quality-of-Life Scale Physical Health score average
decreased as their complaints about menopausal
symptoms increased (Table 4).
The frequency and strength of complaints about
menopause depend on the woman. Some women feel
these complaints strongly, others do not, and all are
affected at different levels. In the literature, excess
amounts of weak estrogenic compounds in women’s
diets are mentioned as a possible important factor that
affects this variation. It is emphasized that the
problems arising from menopause can be prevented by
increasing the consumption of herbal estrogen and
increasing serum concentrations of compounds with
estrogenic activity that acts as selective estrogen
receptor modulators. Phytoestrogens have received
increasing amounts of attention as natural treatments
that solve the problems of menopause.1,2
Brzezinski et al12 performed another study to
determine the effects of a diet rich in phytoestrogen on

TABLE 3. Physical and Mental Health Score Averages on the SF-36 Quality-of-Life Scale According to Visit
SF-36 Quality-of-Life Scale Physical Health Score Average
Visits Experimental Group 1 Experimental Group 2 Experimental Variable Group Control Group

First visit 38.93 ± 8.53 38.63 ± 7.07 37.29 ± 5.98 34.94 ± 6.15
Last visit 49.00 ± 8.55 41.69 ± 4.58 34.65 ± 6.71 33.82 ± 5.29
Wilks λ =0.70; P = .00
SF-36 Quality-of-Life Scale Mental Health score average
First visit 40.63 ± 8.01 40.61 ± 7.35 40.02 ± 6.62 41.37 ± 6.99
Last visit 42.39 ± 5.00 43.36 ± 4.63 41.13 ± 7.08 39.29 ± 7.18
Wilks’ λ = 0.92; P = .01

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156 HOLISTIC NURSING PRACTICE • MAY/JUNE 2015
TABLE 4. Correlations Between the SF-36 Quality-of-Life Scale Physical and Mental Health Score Averages
and the Menopause Rating Scale Score Average
SF-36 Quality-of-Life Scale Experimental Group 1 Experimental Group 2
Physical Health −0.45a
Mental Health −0.62a
a
P < 0.05.
the complaints of women in the climacteric period.
The women in the experimental group were given a
diet rich in phytoestrogen (flaxseed, soy) for 12 weeks
(n = 78) and nothing was given to the control group
(n = 36). At the end of 3 months, the scores of the
women in the menopausal group for menopausal
symptoms, hot flashes, and vaginal dryness were
significantly decreased, whereas the variation in the
control group was insignificant.12 In a randomized
controlled study by Lewis et al,13 the effects of soy
flour and flaxseed on quality of life and the frequency
and strength of hot flashes in postmenopausal women
were studied. Over 4 months, flaxseed were given to
28 women, soy flour was given to 31 women, and
cookies made of wheat flour were given to 28 women.
At the end of the study, the strength of the hot flashes
was reduced in the women who ate flaxseed compared
with the women who ate wheat flour.13
In another randomized controlled study conducted
by Dodin et al6 on postmenopausal women, 40 g of
flaxseed per day was given to the experimental group
(n = 101) for 12 months and wheat seed was given for
12 months to the control group (n = 98). At the end of
the study, no difference was found in the decreases in
vasomotor symptoms.6 In a study by Simbalista et al,9
who analyzed the effects of flaxseed on climacteric
symptoms, no differences were observed between the
control group and the experimental group (to whom
25 g of flaxseed per day was given for 12 weeks).9
Across the literature, the results of studies of alternative
herbal treatment of menopausal symptoms are variable
and inconsistent.5,8,17-21 It has been hypothesized
that this variation is due to nonstandardized
application periods and amounts of flaxseed used.
In the present study, a significant decrease in
menopausal symptoms was observed in the
experimental groups that were given 5 g per day over
12 weeks. Notably, similar decreases in menopausal
symptoms were observed in the experimental group
that received HRT (10%) and the experimental groups
(group 1, 8.7%; group 2, 9.8%) that were given
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Menopause Rating Scale
Experimental Variable Group Control Group
−0.48a −0.36a −0.35a
−0.60a −0.56a −0.39a
flaxseed. Women prefer to use flaxseed because of
ease of use and the absence of side effects compared
with HRT.
Kang et al8 found that women prefer
complementary treatments to HRT because they find
the complementary treatments dependable and do not
want HRT due to its cancer risk and the bleeding it
causes. In this study, the authors found that
menopausal symptoms can be treated with
complementary treatment methods and that 80% of
women aged between 45 and 60 years used
complementary treatments without any recipe to cope
with menopausal complaints.8 In study by MacLennan
et al22 in Australia, the authors found that 48.5% of
women used complementary treatments and that the
women who most frequently used complementary
treatments were in their premenopausal period.22
In this study, the greater decrease in the average
score on the Menopause Rating Scale observed in
experimental group 2 (9.8%) is hypothesized to be due
to the training given to them by the researcher. This
training was given to the women to inform them about
menopause, to help them cope with symptoms,
minimize their risk of illness triggered by menopause,
and develop preventive behavior regarding these
issues. The researcher hypothesizes that the training
given to experimental group 2 allowed the women to
cope with the symptoms.
In a study of climacteric women, Ertem10 found a
significant difference in menopause knowledge
between an experimental group that was given training
and a control group.10 Ergol11 found a positive
relation between knowledge about treatment methods
and the application of those methods to menopausal
complaints. Thus, through training, women can be
thought to cope with menopausal complaints and these
complaints can be decreased.11
Moreover, it is likely that the questions that were
asked of the control group on the first visit caused the
women to be being aware of the symptoms and thus
increased the strength of their complaints.
 Effects of Flaxseed on Menopausal Symptoms and Quality of Life
In the present study, experimental groups 1 and 2
exhibited increases in the average mental and physical
health scores on SF-36 Quality-of-Life Scale
(P < .05). Lewis et al13 found that quality of life
increased due to flaxseed use and that hot flash
complaints decreased.13 No significant difference was
found in the changes in the quality of life change at
the end of 12 weeks between the experimental group
that was given 40 g of flaxseed per day and the control
group that was given wheat seeds in the study of
Dodin et al.6
In this study, the reason for the increase in the
quality of life in the experimental group was likely
due to the flaxseed use and the training that was given
on the phone regarding coping with complaints by the
researcher. On the phone, the women spoke about
their complaints comfortably with the researcher and
their questions were answered.
Women who are aware of the menopause period
and its associated changes and complaints and know
techniques for coping with the changes and
complaints can welcome menopause with more ease
and develop techniques to cope with it. The significant
increase in the mental health score averages of the
women in experimental group 2 (who were given
training about menopause) supports this theory. The
greater increase in the mental health score averages
observed in experimental group 2 is hypothesized to
be due to the use of flaxseed for 3 months, training,
and the phone-based assistance.
In this study, a weak or medium strength negative
relation was found between the total score average
Menopause Rating Scale score and the SF-36
Quality-of-Life Scale Mental and Physical Health
score average (P < .05). This result indicates that the
SF-36 Physical and Mental Health Quality-of-Life
Scale score decreased as the women’s complaints
about menopause increased.
CONCLUSIONS
In this study, a decrease in menopausal symptoms and
an increase in the quality of life among the women
who used flaxseed for 3 months were observed. This
difference was found to be greater among the women
who used flaxseed and also received training about the
menopausal period. These results can serve as a
reference for clinical care providers to apply to
women in the menopausal period.
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157
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