HRT – so what are the alternatives?

NICOLA HILLSSwindon/Bath GP Registrar DRC

December 2005

Why?

Recent research raised concern re HRTExplosion in alternatives availableInternet full of herbal remedies

What remedies do you recommend doctor?

Aims

Overview of alternatives to HRTKnow your black cohosh from your dong

quai……..

Menopause

Average age 51.>9 million postmenopausal women in UKPerimenopausal transition period lasts 4

yrs on averageSymptoms due to low oestrogenVasomotor instability affects 75%, 25%

severely.

Hot flushes (60% experience,most common symptom), sweats, headaches, tiredness, irritability, poor memory, sleep disturbance, depression, anxiety, loss of libido, dry skin, vaginal atrophy, osteoporosis…..

HRT

Very effective at treating symptoms of menopause.

Until recent studies (Women’s Health Initiative and Million Women Study), widely used for long periods

Since media reports of recent studies, over 70% American women and 50% British women stopped HRT.

Due to recurrence of symptoms, many keen to or have already restarted HRT.

But are there any alternatives?

Medical alternatives to HRT

Progestogens eg norethisterone can help control vasomotor symptoms, but can increase risk of TED.

SSRIs eg venlafaxine, paroxetine, for hot flushes. New finding, only small studies.

Gabapentin can also help relieve hot flushes

Clonidine can help flushes, common side-effects of dry mouth, drowsiness, dizziness and nausea limit use.

Bisphosphonates/SERMs for osteoporosis

Vaginal lubricants and topical oestrogens for vaginal dryness etc

Lifestyle – exercise, reduce stress, avoid spicy foods, caffeine and alcohol

Complementary therapies

Little evidence to support use but many women use them, ‘safer’ ‘more natural’.

Little known re active ingredients, safety, side-effects, interactions, and contaminants.

Phytoestrogens and herbal remedies used.

Phytoestrogens

Plant substances that have effects similar to oestrogen.

Bind to oestrogen receptors, acting like hormone regulators.

Most important groups are isoflavones and lignans.

Isoflavones found in soybeans, chick peas, red clover, and other legumes.

Oilseeds like flaxseed, bran, whole cereals, vegetables, legumes and fruit contain lignans.

Observation made that populations with diets high in them eg Japanese have lower rates of menopausal symptoms, CVR disease, osteoporosis and many cancers.

Studies small, lack power and use different methodologies. One review, only 3 out of 12 RCTs reduced hot flushes.

Red clover

Perennial herb, abundant in UKUse flower headBeen used to treat whooping cough,

gout, eczema and cancersContain isoflavones3,570,000 sites on Google.£11.99 for 100 capsules at Holland &

Barrett!

Thought to have anticoagulant properties, so should avoid use with warfarin.

Overall, evidence shows not better than placebo at controlling hot flushes, but widely used in UK.

Black Cohosh

aka black snakeroot, bugwort.Member of buttercup family.Widely used by Native Americans for

colds, arthritis, malaria, sore throats, female infertility, labour pain and miscarriage.

Formulations inc tablets, capsules, liquid and tincture.

Remifemin most widely used product.Used a lot in Germany.40mg BD dose often used.Large doses can cause dizziness, slow

HR, headaches, joint pain and uterine contractions

1,950,000 sites on Google

90 capsules £6.89 at H&B, currently 50% off!

Debate over whether contains phytoestrogens

Seems to have more positive evidence than others.

However formulation and regimen vary between studies.

No evidence that is safe to use if have breast cancer, so should avoid.

More rigorous studies are underway

Dong quai

Chinese herbal medicineGrows in China, Korea and JapanUse dried roots, can be used as tonic,

tincture or in capsulesAlso used for constipation, PMS, and

anaemia.Often used in combination with other

herbs

870,000 sites on Google£8.99 for 100 capsules at H&B, currently

50% off!Only one published RCT, no better than

placebo in reducing menopausal symptoms

Shouldn’t use with warfarin, can also cause rashes, ? cancers

Kava

Traditional ritual tranquilising beverage from the rootstock of a plant of the pepper family, native to Vanuatu.

Used for ceremonial purposes, as a symbolic welcome for VIPs, beverage for culminating the marriage ceremony, a relaxant and to ? treat UTIs!

? help mood during menopause

Serious hepatic side-effects have been reported though eg hepatitis, cirrhosis and liver failure.

Prohibition order regarding medicinal products containing kava came into force Jan 2003.

1,870,000 sites on Google

Others

Evening primrose oil, vitamin E, American ginseng, wild yam, sage and St. Johns wort are also used, no controlled studies on their effects on menopausal symptoms.

Conclusions

Still a role for HRT, assess patients symptoms and risk.

Short-term use <5 yrs, lowest oestrogen dose and regular reviews.

Further evidence re HRT safety emerging.

Need further quality research into complementary therapies.

Most evidence for Black cohosh, but preparations/doses vary.

Vast amount of misleading info on net

Useful websites

www.menopausematters.co.ukwww.the-bms.org