Menopause - Alternatives to HRT
The menopause can cause various symptoms such as hot flushes and changes to your vagina and genital skin. Hormone replacement therapy (HRT) eases your symptoms.
This leaflet discusses alternatives to HRT which may ease menopausal symptoms.
What is the menopause?
Strictly speaking, the menopause is your last menstrual period. However, most women think of the menopause as the time of life leading up to, and after, their last period. In reality, your periods don't just stop. First they tend to become less frequent. It can take several years for a woman to go through the menopause completely. Women are said to have gone through the menopause (be postmenopausal) when they have not had a period at all for one year.
What causes the menopause?
A natural menopause occurs because as you get older your ovaries stop producing eggs and make less of the main female hormone called oestrogen. The average age of the menopause in the UK is 51. Your menopause is said to be early if it occurs before the age of 45 and is called Premature Ovarian Insufficiency if it occurs before the age of 40 years.
There are certain things that may cause an early menopause. For example:
- If you have surgery to remove your ovaries for some reason, you are likely to develop menopausal symptoms straightaway.
- If you have radiotherapy to your pelvic area as a treatment for cancer.
- Some chemotherapy drugs that treat cancer may lead to an early menopause.
- If you have had your womb (uterus) removed (a procedure called hysterectomy) before your menopause. Your ovaries will still make oestrogen. However, it is likely that the level of oestrogen will fall at an earlier age than average. As you do not have periods after a hysterectomy, it may not be clear when you are in 'the menopause'. However, you may develop some typical symptoms (see below) when your level of oestrogen falls.
- An early menopause can run in some families.
- In many women who have an early menopause, no cause can be found.
Early menopause and premature menopause are not discussed in detail in this leaflet.
What are the possible symptoms and problems of the menopause?
The menopause is a natural event. Every woman will go through it at some point. You may have no problems. However, it is common to develop one or more symptoms which are due to the low level of oestrogen. About 8 out of 10 women will develop menopausal symptoms at some point. Around a quarter of women have very severe symptoms.
Symptoms of the menopause can last much longer than most women realise. More than half of women actually have symptoms for more than seven years.
These short-term symptoms only last for a few months in some women. However, for others they can continue for a few years after their last period:
- Hot flushes occur in about 3 in 4 women. A typical hot flush lasts a few minutes and causes flushing of your face, neck and chest. You may also sweat (perspire) during a hot flush. Some women become giddy, weak, or feel sick during a hot flush. Some women also develop a 'thumping heart' sensation (palpitations) and feelings of anxiety during the episode. The number of hot flushes can vary from every now and then, to fifteen or more a day. Hot flushes tend to start just before the menopause and can persist for several years.
- Sweats commonly occur when in bed at night. In some cases they are so severe that sleep is disturbed and you need to change your bedding and nightclothes.
- Other symptoms may develop, such as headaches, tiredness, being irritable, difficulty sleeping, depression, anxiety, aches and pains, loss of sex drive (libido), and feelings of not coping as well as before.
- Changes to your periods. The time between periods may shorten in some women around the menopause; in others, periods may become further apart, perhaps many months apart. It can also common for your periods to become a little heavier around the time of the menopause.
Longer-term changes and problems
- Skin and hair. You tend to lose some skin protein (collagen) after the menopause. This can make your skin drier, thinner and more likely to itch.
- Genital area. Lack of oestrogen tends to cause the tissues in and around your vagina to become thinner and drier. These changes can take months or years to develop:
- Your vagina may shrink a little, and expand less easily during sex. You may experience some pain when you have sex.
- Your vulva (the skin next to your vagina) may become thin, dry, and itchy.
- You may notice that you need to pass urine more frequently.
- Some women develop problems with recurrent urine infections.
- 'Thinning' of the bones (osteoporosis). As you become older, you gradually lose bone tissue. Your bones become less dense and less strong. The amount of bone loss can vary. If you have a lot of bone loss then you may develop osteoporosis. If you have osteoporosis, you have bones that will break (fracture) more easily than normal, especially if you have an injury such as a fall. Women lose bone tissue more rapidly than men lose it, especially after the menopause when the level of oestrogen falls. Oestrogen helps to protect against bone loss.
- Cardiovascular disease. Your risk of cardiovascular disease (disease of the heart and blood vessels), including heart disease and stroke, increases after the menopause. Again, this is because the protective effect of oestrogen is lost. Oestrogen is thought to help protect your blood vessels against atheroma (small fatty lumps that develop within the inside lining of blood vessels). Atheroma is involved in the development of heart disease and stroke.
What is hormone replacement therapy (HRT)?
All types of HRT contain an oestrogen hormone. If you take HRT it replaces the oestrogen that your ovaries no longer make after the menopause. HRT is excellent at preventing hot flushes, vaginal dryness and related vaginal symptoms. It can also help to improve sleep if your sleeping pattern is affected by the menopause. Long-term use of HRT also has a benefit in helping to prevent 'thinning' of your bones (osteoporosis) and can also reduce the likelihood of developing coronary heart disease in some women. HRT is much safer than many people realise. See separate the leaflet called Menopause and HRT for more details.
Some women may choose not to take HRT or others may not be able to take HRT due to an underlying medical condition. If you are not sure whether or not you can take HRT then you should discuss this with your doctor who will be able to refer you to an expert in the menopause.
The rest of this leaflet discusses some other treatment options for menopausal symptoms.
Non-HRT treatments for hot flushes and night sweats
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.
SSRIs and SNRIs
Selective serotonin reuptake inhibitors (SSRIs) are a class of antidepressant medicine. They include paroxetine, fluoxetine, escitalopram 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 drug 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 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.
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 and many of these are not 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.
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 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.
Non-HRT treatments for vaginal dryness
You can buy vaginal lubricants and moisturisers from pharmacies, which can help ease vaginal dryness. 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. See separate leaflet called Atrophic Vaginitis for more details.
Non-HRT treatments for preventing osteoporosis
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.
- 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 help & information
PO Box 183, Rossendale, BB4 6WZ
pracklen House, East Wing Dukes Place, Marlow, Bucks, SL7 2QH
Tel: 01628 890199
Further reading & references
- Menopause: diagnosis and management; NICE Guidelines (Nov 2015)
- No authors listed; Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society. Menopause. 2015 Nov;22(11):1155-74. doi: 10.1097/GME.0000000000000546.
- Palacios S, Mejias A; An update on drugs for the treatment of menopausal symptoms. Expert Opin Pharmacother. 2015 Nov;16(16):2437-47. doi: 10.1517/14656566.2015.1085508. Epub 2015 Sep 22.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Patient Platform Limited has used all reasonable care in compiling the information but makes no warranty as to its accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Louise Newson
Prof Cathy Jackson