Alternatives to HRT

Authored by Dr Jacqueline Payne, Reviewed by Dr Sarah Jarvis MBE on | Certified by The Information Standard

Some women may choose not to take HRT or others may not be able to take HRT due to an underlying medical condition.

The menopause can cause various symptoms such as hot flushes and changes to your vagina and genital skin. While some women will wish to take Hormone replacement therapy (HRT) to relieve their symptoms, others will prefer to consider alternative treatments which may ease menopausal symptoms. 

Lifestyle

There is some evidence that healthy lifestyle behaviours can improve some symptoms of the menopause - for example, hot flushes and night sweats. In addition, weight loss, mindfulness and cognitive behavioural therapy can have also a mild-to-moderate effect on these symptoms.

There is also some evidence that women who are more active tend to have fewer symptoms of the menopause. However, not all types of activity lead to an improvement in symptoms. High-impact exercise done now and then may even make symptoms worse. The best activity is regular sustained aerobic exercise, such as regular swimming or jogging.

Wearing lighter-weight clothing, sleeping in a cooler room and reducing stress may reduce the number of hot flushes. Some women find that things such as spicy foods, caffeine (in tea, coffee, cola, etc), smoking, and alcohol may trigger hot flushes. Avoiding these things may help for some women.

 

Complementary and alternative treatments

Some women consider taking complementary and alternative treatments instead of taking HRT. There is a massive market for products to help with menopausal symptoms but many of these are not proven to be safe or do not have good research to support their effectiveness.

For example, the following have been marketed for menopausal symptoms: black cohosh, red clover, dong quai, evening primrose oil, ginseng, soy and St John's wort. However, just because a product is labelled 'natural' does not mean that it is automatically safe and free from potentially damaging chemicals.

Herbal remedies are not regulated by a medicine authority and they should not be considered as a safer alternative to HRT, as there is so much variety in their effectiveness and potency. Many herbal medicines have unpredictable doses and purity. In addition, some products have significant side-effects and can interfere with other medicines.

The regulatory bodies have developed a system called Traditional Herbal Registration (THR). Any herbal products that have been approved by this system have a THR logo on their packs. This means that the product has the correct dosage and is of a high quality. The pack will also contain product information in it.

Isoflavones and black cohosh
There is some evidence that isoflavones or black cohosh may improve some symptoms of the menopause. However, multiple preparations of these products are available and their safety is still uncertain. Different preparations can vary and these products can also interfere with other medicines.

St John's wort
St John's wort can improve symptoms in some women. It does not seem to make any difference to low mood or anxiety symptoms though. There is still uncertainty about the most appropriate dose of St John's wort and also how long the effect of taking it lasts for. There is a variation in the nature and potency of different preparations of this product. In addition, it can interfere with other medicines, including tamoxifen.

SSRIs and SNRIs

Selective serotonin reuptake inhibitors (SSRIs) are a class of antidepressant medicine. They include paroxetinefluoxetineescitalopram and citalopram. Several years ago it was noticed as a side-effect that menopausal women who took these medicines for depression had fewer hot flushes. Since then, a few studies have shown that several SSRIs stop or reduce hot flushes in some (but not all) menopausal women, even those who are not depressed. A similar antidepressant medicine called venlafaxine, a serotonin and noradrenaline (norepinephrine) reuptake inhibitor (SNRI) antidepressant, has also been shown to have this effect. How SSRIs and SNRIs work to help hot flushes is not clear.

When it works, an SSRI or SNRI provides relief from hot flushes almost immediately. A trial of one to two weeks is usually enough to find out whether it is going to work or not. If symptoms improve, a longer course may then be prescribed. However, the beneficial effect is often short-acting so does not last for long. The main drawback with these medicines is that they may cause side-effects in some women - for example:

  • Feeling sick (nausea).
  • Reduced sex drive (libido).
  • Reduced sexual response.

Note: You should not take paroxetine or fluoxetine if you are also taking tamoxifen, as these medicines can interfere with each other.

Gabapentin

Gabapentin is a medicine that is usually used to control epileptic seizures and pain. However, research has shown that it can ease menopausal flushing symptoms in some women. Side-effects, such as dizziness and tiredness, can occur with this medication.

Note: strictly speaking, SSRIs, SNRIs and gabapentin are not licensed for treating menopausal symptoms. However, many doctors are willing to prescribe one of these treatments, with the patient's consent, to see if it works.

Other treatments
There is good evidence that cognitive behavioural therapy can improve symptoms of low mood and anxiety which arise as a result of the menopause in some women.

There is conflicting evidence regarding the use of soy and red clover. They should not be taken in women with hormone-dependent breast cancer or those taking tamoxifen.

Bio-identical hormones are also not regulated and are not subject to any quality control.

Clonidine
Clonidine used to be very popular for the treatment of the menopause. However, there is no good evidence that it is beneficial in improving symptoms. It frequently causes side-effects such as dry mouth, drowsiness, dizziness and feeling sick. It is therefore not commonly used any more.

You can buy vaginal lubricants and moisturisers from pharmacies, which can help ease vaginal dryness (atrophic vaginitis). Some women only notice dryness when they have sex. In this situation, placing a small dose of lubricant inside the vagina before having sex will usually help.

Note: you may not be aware that there are oestrogen creams which ease the vaginal symptoms of the menopause. Strictly speaking, they are a form of HRT but have far less risk compared with taking HRT tablets. Read about vaginal dryness (atrophic vaginitis).

Ways to reduce your risk of developing 'thinning' of the bones (osteoporosis) include:

  • Doing regular weight-bearing exercise. This means exercise such as brisk walking, aerobics, dancing, running, etc. For older people, a regular walk is a good start. Exercise helps because the pulling and tugging on the bones by the muscles helps to stimulate bone-making cells and strengthens the bones.
  • Eating a diet that includes foods rich in calcium and vitamin D. If you eat 1,000 mg of calcium each day you have a reduced risk of hip fractures. Ask your practice nurse for advice about diet. Briefly, you can eat 1,000 mg calcium most easily by:
    • Drinking a pint of milk a day; plus
    • Eating 60 g (2 oz) of hard cheese, such as Cheddar or Edam, or one pot of yoghurt (125 g), or 60 g of sardines.
    White bread and calcium-fortified soya milk are also good sources of calcium.
  • Taking dietary supplements of calcium and/or vitamin D tablets if you do not get enough in your diet and you are at increased risk of developing osteoporosis. A dietary supplement of 10 micrograms of vitamin D is recommended for all people over the age of 65.
  • Stopping smoking if you smoke.
  • Cutting down on alcohol if you drink heavily.

If you develop osteoporosis, there are medicines which can help to restore some lost bone and help to prevent further bone loss. See separate leaflet called Osteoporosis for more details.

Further reading and references

  • ; British Menopause Society & Women’s Heath Concern recommendations on hormone replacement therapy, May 2013

  • ; NICE Guidelines (Nov 2015)

  • ; Management of Menopausal Symptoms. Obstet Gynecol. 2015 Oct126(4):859-76. doi: 10.1097/AOG.0000000000001058.

  • ; Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society. Menopause. 2015 Nov22(11):1155-74. doi: 10.1097/GME.0000000000000546.

  • ; Faculty of Sexual and Reproductive Healthcare (August 2017)

  • ; The evidence base for HRT: what can we believe? Climacteric. 2017 Apr20(2):91-96. doi: 10.1080/13697137.2017.1280251. Epub 2017 Mar 10.

  • ; European Society of Human Reproduction and Embryology, 2016

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