Benha University Hospital, Egypt

2005 ABOUBAKR ELNASHAR

36% of adults in the U.S. had used

some form of alternative therapy

within the previous 12 months

46% of women used CAM for

menopausal symptoms.

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Why Alternatives to HRT are

requested?

1. Contraindication to HRT 2. Belief that HRT interfere with nature

3. Fear of long term effects of HRT

4. Fear of adverse effects. 5. Lack of information about HRT

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Facts about alternatives for HRT 1.Most treat only a single problem

2.There is potential harm, because of a lack

of efficacy or possible risks

3.There is a lack of evidence to confirm

benefits or possible adverse effects.

4.There is a widespread belief that “natural”

means harmless, but herbs may contain

potent chemicals & should be used with

caution.

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Alternatives to HRT

1. Lifestyle Changes 2. Dietary changes & supplements

3. Complementary therapies

4. Drugs

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Avoid

•trigger factors for vasomotor symptoms.

•risk factors for osteoporosis.

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1. Avoidance of trigger factors for vasomotor

symptoms:

Alcohol

caffeine,

smoking,

hot or spicy food or drinks,

hot environment &

stress.

Good ventilation, minimal heating & light bed

linen.

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2. Avoidance of risk factors associated with

osteoporosis:

Smoking, alcohol & inactivity.

Smoking is associated with reduced bone formation

due to:

1. the toxic effect of nicotine on osteoblasts or

2. the increased hepatic clearance of oestrogen,

which in turn will increase bone resorption.

Alcohol:

higher risk for breast cancer with even moderate

intake (Stampfer et al, 2005)

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Plan for to quit smoking (Malat,2005):

Pick a quit date,

visualize yourself as a nonsmoker;

seek out support from friends and family;

recognize the triggers and find substitutes; and

consider using medication, such as the nicotine patch

and bupropion.

The most successful method of overcoming the

smoking habit is a combination of both behavior-

modification therapy and prescription drug treatment.

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Excercise: Effects:

1. In early life maximize bone mass & later

help to conserve it.

2. Extremely important to cardiac health,

helping to reduce weight, blood pressure &

cholesterol levels. Women who walked for

1h/w experienced half the CHD risk of women

who did not walked.

3. Reduced incidence of severe hot flushes,

depression & improve mood.

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Type:

Regular

Weight bearing.

The safest excercise is walking

30 minute 4-5 times /w.

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A balanced diet should comprise whole grains,

fruits, vegetables, minerals and vitamins, with

a minimal amount of saturated fats.

Calcium with vitamin D supplementation is

recommended

I. Multivitamins.

II. Minerals.

III. Natural hormones.

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I. Multivitamins

1. Vit E: 400-1200 IU daily

a. Reduces VM symptoms (Kass-

Annesse,2000)

b. Reduces the risk of CHD (100 IU daily for

2 years) {The Nurses health study, 1993).

Low level of Vit E is a better predictor of CHD

than elevated cholesterol or blood pressure (Cooper et al,1994)

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2. Vitamin D: 400 IU daily with calcium

significantly reduced fracture risk (Chapuy et al, 1992)

Oily fish eaten at least twice a week reduced

mortality from CHD (Daviglus et al, 1997)

Garlic: reduction of cholesterol is doubtful (Daviglus et al, 1997)

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II. Minerals:

•Adequate calcium intake: 1500 mg daily:

reduction of hip fracture (Cumming et al, 1997).

•Adequate intake of magnesium is crucial for

osteoporosis prevention (Kass-Annesse,2000).

The dietary ratio of calcium to magnesium is

best maintained at 2:1.

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•Avoid factors increasing urinary

calcium loss . High sodium intake

. High phosphorus (soft drinks such as cola) & may

be damaging for young bone

(Carey & Carey, 1999). . High protein intake, generally in the form of animal

protein (Nordin, 2000).

. High caffeine intake is associated with an increase

in fracture

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III. Natural hormones 1. Phytoestrogens

Asian women experience fewer menopausal

symptoms than western women & their traditional

diet contain high level of phytoestrogens, about 200

mg daily compared with < 5 mg daily in western diet.

Derived from

plants

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Types:

1. Isoflavones:

soya beans (richest source), chick peas,

lentils

2. Lignans:

apples, stone fruits, onion, garlic, seed oils,

cereals, fruit & vegetables.

3. Coumestans:

clover

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Available in:

tablet (Klimadynon=cimicifugae)

food supplements in bread,

snack bars,

health drinks.

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Activities:

oestrogenic, anti-oestrogenic, depending on

target tissue & endogenous levels of sex

hormones (Tham et al,1998)

antiviral, anticarcinogenic, bactericidal,

antifungal, antioxidant, antimutagenic,

antihypertensive, anti-inflammatory, &

antiproliferative effects.

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Effects 1. Reduction of menopausal symptoms &

Prevention of osteoporosis: data are conflicting.

2. FDA has approved food substances containing

soy protein to reduce the risk of heart disease.

Adverse effects:

No adverse effects

Risks: No RCT. So, it is not possible to draw absolute

conclusions. Evidence to date on whether it is

protective is inconclusive (Weaver & Cheong, 2005)

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2. Natural progestagen creams:

Extracted from: plant source, mainly

yams & soya.

Effects: An improvement in vasomotor

symptoms but no effect on bone (DTB, 2001)

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3. Dehydroepiandrosterone (DHEA)

Available as:

a food supplement.

Effects:

improved mood, sleep, tiredness & ability to

cope (Thaker & Booher, 1999).

Adverse effects:

lowering HDLP, increasing insulin resistance

& raising blood pressure

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1. Herbalism.

2. Acupuncture.

3. Stress reduction.

4. Homoeopathy.

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•There are over 100 therapies

•Limited evidence to support their efficacy or safety (Brockie, 2002).

•May help with the short term problems not the

long term.

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1. Herbalism:

There is a number of known drug-herb

interactions.

In Germany, herbs are classified as drugs &

regulated by Commission E (Blumennnthal,1998).

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A.Black cohosh (Cimmicifugae racemosae) Binds to estrogen receptors & suppresses

luteinizing hormone (Viereck et al, 2005)

Effective in alleviation of vasomotor

symptoms, insomnia & low mood (Mckenna et al, 2001).

Daily dose: 40 mg & no longer than 6

months.

No drug interaction.

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B. St John s Wort (Hypericum) Dose: 900 ug daily.

Effective in reducing flushes, low mood,

insomnia mild-to-moderate depression (Grube et al, 1999).

Drug interactions with theophylline, digoxin,

cyclosporin, combined oral contraceptive

pills.

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Valerian: contains a gamma aminobutyric acid (GABA)

used as a tranquilizer and soporific. Chamomile tea also

contains a GABA-like compound and is preferred as a sleep

aid.

Sage, chste tree, dong quai, ginseng, gingko biloba,

kava, garlic, & feverfew: Comission E does not recommend them for use at menopause

(2002) because of Limited scientific data or adverse side

effects.

Oil of evening primrose: not effective in a placebo RCT (Chenoy et al, 1994)

Chinese herbs: not effective in placebo RCT (Davis et al, 2001)

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2. Acupuncture:

Significant reduction in vasomotor symptoms

& the benefits continued for 3 weeks (Wyong et al, 1995; Tukmachi, 2000).

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3. Stress reduction:

•Encouraging women

to reassess their priorities in life,

to reduce unnecessary stress that in turn may

alleviate some symptoms.

•Relaxation exercises were found to decrease

the number of hot flashes.

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Simple deep breathing periodically through-

out the day for approximately 1 minute

reduces hot flashes up to 50% (Wijma et al, 1997).

Support groups for menopausal women: To

overcome the feeling of isolation.

Some women use alternative measures to

reduce stress, including yoga, massage,

biofeedback, acupuncture, and hypnosis.

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4. Homoeotherapy:

•A comprehensive system of medicine based on

the principle of “like cures like” relying on the use

of a highly diluted solution of a substance. High

concentrations of a substance may induce

symptoms of the disease, where as the same

substance in a highly diluted solution may treat the

disease.

•It has many skeptics, although as an alternative

treatment, it is safe.

•RCT are needed to clarify its value in the

menopause.

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Aromatherapy (the use of smells, pleasant &

unpleasant to induce certain health benefits,

relaxation or emotions), massage &

reflexology:

No scientific evidence to show any benefit on

menopausal symptoms. They are helpful in

stress reduction.

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I. For prevention & treatment of osteoporosis

II. For treatment of vasomotor symptoms

III. For symptomatic treatment of atrophic

vaginitis

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Many are effective but only for single problem.

I. For prevention & treatment of osteoporosis

1. Bisphosphonates

2. Raloxifene

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II.For treatment of vasomotor symptoms

1. Antidepressants:

For hot flushes. Also positive effect on mood &

libido,

Adverse effects: dry mouth, nausea,

constipation, & reduced appetite

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Paroxetine (Seroxat) 20 mg daily

67% reduction in hot flushes (Stearns et al, 2000)

Venlafaxine (Efexor) 75 mg daily

61% reduction (Loprinzi, 2000) (RCT).

The benefits are seen within a couple of

weeks.

Venlafaxine 37.5 mg daily: 37% reduction of

hot flushes & fewer adverse effects

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2. Night sedation:

For insomnia & mood swings

3. Veralipide (Agreal): 100 mg daily for 20 days, repeated after 7

days. It is neuroliptic

4.Gabapentin (Neurontin):

used to treat seizures, has achieved

reductions in the number or severity of

vasomotor symptoms within 1 week (Guttuso, 2000).

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5.Bellergal-Retard:

phenobarbitone (central sedative 40 mg),

belladona (parasympathetic inhibitor, 0.2

mg), ergometrin tartarate (sympathetic

inhibitor, 0.6 mg) one tab twice daily

6. Clonidine (catapress):

0.1 to 0.2 mg twice daily

Rarely used because 30 % reduction which

is little different from placebo (Laufer, 1982)

7. Propranolol:

No data to support its use (Brockie, 2002)

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III. For symptomatic treatment of atrophic

vaginitis

1. Simple vaginal lubricants: Astroglide,

Lubrin, replens

2. Long acting bioadhesive vaginal

moisturiser: Gynemoistrin

It is comparable to vaginal estrogen

preparation (Nachtigal,1994).

It is a gel containing water & polycarbophil

that adhere to the vaginal wall, encouraging

water back into the dehydrated cells. Each

application lasts for about 3 days.

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3. Vaginal estriol or estradiol:

It is not absorbed systemically to any

significant degree.

They can be used safely in

.women with a contraindication to systemic

estrogen &

. in a long term without any effect on the

breast or endometrium (Brockie,2002).

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1. Alternative therapies can offer treatment

options to women who either have a

contraindication to HRT or who prefer to

avoid it.

2. Alternatives to HRT are associated with

potential harm, because of a lack of efficacy

or possible risks

3. Most alternatives treat only a single

problem

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4. There is a lack of evidence to confirm

benefits or to highlight possible adverse

effects.

5. Alternatives to HRT include Lifestyle

changes, dietary changes & supplements,

complementary therapies & alternative

drugs.

6. Prtocol of Oxford Menopause Clinic,

2002.

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