Which HRT alternatives are worth trying?

Glynis Kozma and Ruth Doherty
Photo credit: piolka

From Prima

If you're going through the menopause, you may wonder what HRT alternatives are available. Whether you just don't like the idea of taking HRT or are struggling to get hold of some with the current HRT shortages, we look at the alternative ways to manage menopause symptoms.

Although the majority of women can use HRT with minimal risk, some health conditions may take away that choice; for example, blood clots or heart disease, women's cancers, or a strong family history of breast cancer amongst first-degree relatives.

What's more, a recent study, published by The Lancet, suggests that women who use HRT for longer than one year have a higher risk of breast cancer than women who never use HRT. This known risk of breast cancer gets lower once HRT is stopped, but the new study shows some increased risk remains for more than 10 years compared to women who have never used HRT. The increased risk of breast cancer is seen with all types of HRT, except for topical HRT applied directly onto or into the vagina.

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There is no need for urgent action but women who use, or are planning to use, HRT should be aware of these new findings when considering their HRT use at their next routine appointment. Women who have previously used HRT should be vigilant for signs of breast cancer and see a doctor if they notice any changes in their breasts. It is also important for all women to go to breast screening when invited.

The MHRA (Medicines and Healthcare products Regulatory Agency) advises that HRT should only be initiated for relief of menopausal symptoms that adversely affect quality of life.

Women should use the lowest effective dose of HRT for the shortest duration and HRT should only be continued as long as the benefit in alleviating menopausal symptoms outweighs the risks associated with treatment. In all cases, a careful appraisal of all the risks and benefits should be undertaken regularly, as a woman’s need for treatment and chance of side effects changes over time. Each women’s risk will depend on what type of HRT is used and how long it is used for. Your doctor or nurse can tell you more about your risks. If you're not happy to take any risks, you may want to consider HRT alternatives.

HRT alternatives

If you think HRT isn't for you, there's a huge selection of vitamins, supplements, herbs, alternative therapies, diets, and even magnets that claim to help menopausal women, but it can be difficult to know which to go for.

It's not easy choosing a product off the shelf in a supermarket; the vitamin and supplements industry is a booming business with one aim: to make a profit. Furthermore, some over-the-counter products are potentially dangerous, in exactly the same way as prescribed medicines are, for some people.

The Royal College of Gynaecologists (RCOG) has produced guidelines on HRT alternatives, based on if you don't want to use HRT, or can't use it.

It says the alternatives to HRT can be broadly classified as:

  • Herbal medicine– a practice based on the use of plants or plant extracts to relieve symptoms
  • Alternative medicine – a range of therapies used instead of conventional medicine, such as acupuncture
  • Complementary therapy – interventions that tend to be used alongside conventional medicine
  • Non-hormonal medical treatments – treatments prescribed by your doctor, such as antidepressants.

Discover the best HRT alternatives below:

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Lifestyle choices for the menopause

  • Regular aerobic exercise can help insomnia and depression. There is no evidence that exercise alone can relieve hot flushes.
  • Yoga - there is some evidence it can reduce hot flushes and improve overall feelings of wellbeing. Find a yoga class near you and check out these beginner yoga poses.
  • Reduce stress and anxiety, which can exacerbate a hot flush attack. Work on steadying your breathing, says Lynne Robinson, pilates guru and Body Control Studio founder. She said: "Pilates improves your breathing which will help you relax, and improve stamina and endurance. Pilates can also help to improve the stability and mobility of your joints so that your body moves efficiently and without strain, restoring balance." Check out our beginner's guide to Pilates.
  • Reducing or eliminating caffeine and alcohol will help reduce hot flushes and night sweats. Dr Marilyn Glenville, a leading UK nutritionist and author of Natural Solutions to Menopause, says: "Hot drinks before bedtime can often trigger night sweats or even make them worse. Try to stay away from caffeine, alcohol and spicy foods. Remember, that caffeine can be found in both food and drink (chocolate, caffeinated soft drinks, energy drinks, coffee and tea). It can cause your blood vessels to expand making you sweat more, which can increase the hot flushes. You can also sip a cold drink during the day. If you feel a hot flash coming on, this can help lower your body's temperature."

Herbal medicine for the menopause

This is one of the most popular alternative treatments but the choices can be very confusing. 'Natural' does not automatically mean 'safe'. Some herbal treatments are risky due to side effects, unsuitable for women who are at risk of breast cancer, and may be dangerous when used with other herbs or prescribed drugs. They aren't a magic wand, no matter how well they are promoted by the manufacturers.

The RCOG says: "The best remedies can reduce the severity of symptoms by 50%-60% compared with 80%-90% for HRT."

So, which herbal treatments may help as HRT alternatives?

Black cohosh may work, but more research is needed. It can create upset stomachs and skin rashes. Very rarely it can cause problems with the liver, so if you have, or had, liver disease be careful.

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On the positive side? Nutrition expert Dr Marilyn Glenville says black cohosh is the herb of choice for hot flushes, explaining: "What’s important is that it does not increase oestrogen levels and has no effect on cells in the vagina or womb.

"This is vital because this is where the risks are with HRT, which increases oestrogen levels and stimulates tissue in various places in the body (including the womb and breast) and therefore can increase the risk of cancer.

"Black cohosh offers relief without oestrogen-like effect. So how does it work? It acts as a SERM – selective oestrogen receptor modulator – promoting it in organs where oestrogen is needed, such as the bones, while acting as an ‘anti-oestrogen’ in organs where unnecessary oestrogen can be dangerous, for example the breast and womb."

Herbs that don't work for treating menopause symptoms

  • agnus castus
  • ginko biloba
  • hops
  • sage leaf
  • valerian root
  • evening primrose
  • ginseng
  • dong quai
  • kava kava

According to the RCOG: "There are very few studies on whether these work." Many women think that evening primrose works but, although it's useful for PMS and breast pain, there is no evidence it works on hot flushes.

Herbs that may have some benefit in the menopause

St John's Wort appears to be effective for treating depression, but it can interfere with many other commonly prescribed drugs. The RCOG advises: "Talk to your GP or pharmacist before mixing it with other prescribed or non-prescribed medication."

Red clover may work for hot flushes and night sweats but more studies are needed. The RCOG warns: "It may work like an oestrogen and it's not clear if it's safe to use if you have been advised to avoid oestrogen."

Phytoestrogens and supplements

These are supplements derived from plants and have an effect similar to weak oestrogens. At one time, these were thought to help with menopausal symptoms, but the studies are not consistent enough to be sure.

A good source of phytoestrogens is soya and women are often advised to start eating more, for instance yoghurts, soya milk and foods rich in phytoestrogens – peas, beans and chickpeas.

However, the RCOG says: "The results are not consistent. More studies are needed. Of all soy products, the supplement isoflavone appears to have the most benefit. However, you should only use it if your periods have stopped because if you take the supplement for a long time it may affect the lining of your uterus so any unusual bleeding post-menopause must be reported to your doctor."

DHEA is a supplement which, according to the RCOG, "may have a positive effect on memory, libido, and potentially, vaginal dryness. However, the long term effects are unknown."

Other HRT alternatives for menopausal symptoms

Cognitive Behavioural Therapy (CBT)

The RCOG links to a site called Women's Health Concern, that states CBT – a talking therapy that can help you manage your problems – could help alleviate menopausal symptoms. It reads: "The good news is that CBT can alleviate low mood and anxiety which arise as a result of the menopause, and now we realise CBT can also improve hot flushes and sweats.

"The North American Menopause Society (NAMS) recommends a CBT approach that combines relaxation techniques, sleep hygiene and learning to take positive healthy attitude to a menopause challenge.

"CBT is now a recommended treatment option for anxiety experienced during the peri and post-menopause. A CBT approach which is theory based can improve hot flush perception and reduce stress and sleep problems."

Acupuncture

Acupuncture may help reduce night sweats and hot flushes though more research is needed to be sure it's not a placebo effect.

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Magnets

In the form of bracelets, necklaces and even a 'magnet in your knickers'. There is no evidence at all that these work. Any benefits are likely to be the placebo effect – believing that they do work, which may help mood and therefore severity of symptoms – or because menopausal symptoms vary so much from week to week and month to month.

Reflexology

More studies are needed. It is safe but there is no evidence it works. It won't cause harm so if you want to try it, go ahead.

Aromatherapy

Anything that helps you feel good is useful. There is no evidence that aromatherapy helps long term with menopausal symptoms, but if you feel good after a lovely scented massage, why not?

Progesterone skin creams

There is a large industry which promotes the use of these creams, promising they can help menopausal symptoms and bone density. A US and UK study showed no increase in bone density over two years (as noted on the website of the National Osteoporosis Society) and no studies which show without doubt that the cream helps menopausal symptoms.

Treatments available on prescription

These may help but, as with all drugs, the benefits are often balanced with possible side effects which affect everyone differently.

Antidepressants

Some doctors offer women antidepressants for hot flushes and other menopausal symptoms. The most effective appears to be Venlaxifine. However, bear in mind that these drugs can cause nausea and other side effects.

The latest NICE report on the menopause makes it clear that GPs should not offer these drugs for hot flushes or low mood in place of HRT when women can safely use HRT: "Do not routinely offer SSRIs and SNRIs (types of antidepressants} as first-line treatment for vasomotor symptoms alone."

The placebo effect and menopause hormones!

Always bear in mind that what works for one person may or may not work for you. This applies to prescribed drugs and anything you buy over the counter. One factor to consider with menopausal symptoms is that they can vary hugely from week to week and month to month.

If your periods haven't stopped but are irregular, even a tiny rise in your oestrogen levels (which can happen hourly, daily or weekly) can make your symptoms improve. It's very easy to think that the herbal product you are trying is working, when in fact it's your own hormonal fluctuations.

It's clear from the guidance from the RCOG that much more research is needed on many herbal products, but the most important factor is to make sure you don't use anything that may cause you harm.

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