Alternative to HRT in the menopause (perimenopause)

The following can be used as alternative therapies to HRT in the management of symptoms of menopause:

• lifestyle measures
  • evidence suggests that regular sustained aerobic exercise such as swimming or running improve several common menopause-related symptoms (infrequent high-impact exercise should be avoided as it can make symptom worse)
  • avoidance or reduction of alcohol and caffeine intake may help to reduce the severity and frequency of vasomotor symptoms (1,2)
    
    
• pharmacological alternatives
  
  
  • gabapentin - has shown efficacy for hot flush reduction - a 45% reduction in hot flush frequency and a 54% reduction in symptom severity was seen with a dosage of 900 mg/day (2)
    • may be beneficial for the symptoms of aches, pains and paraesthesia (3)
    • possible adverse effects include dry mouth dizziness and drowsiness with a very specific dose related component; weight gain (4)
      
      
  • pregabalin
    • dosage 50-300mg in divided doses; baseline improvement similar to gabapentin (4)
      
      
  • clonidine -
    • has been shown to reduce hot flushes
    • dosage 25-50 micrograms bd up to a maximum of 75 micrograms bd or 50mcg tds (4)
    • may complement other antihypertensive drugs; only licensed option (4)
    • considerations/adverse effects - interaction with anti-hypertensive drugs and not suitable for patients with baseline low blood pressure; must be reduced gradually otherwise causes rebound hypertension; dose related side-effects include sleep disturbance in at least 50% of patients, dry mouth nausea and fatigue (4)
      
      
  • selective serotonin and noradrenaline reuptake inhibitors (SSRIs & SNRIs) (4)
    
    • SSRIs as an alternative to HRT - general principles
      • in general baseline effectiveness 20-50%
      • class effect of SSRIs are of antidepressant benefit and improved quality of life
      • class effect of SSRIs include initial side effects such as nausea, dizziness, shortterm aggravation of base-line anxiety and mood, so encourage your patient to persevere and if necessary take on alternative days, even ½ tablet
      • class effect of all SSRIs is sexual dysfunction- no one SSRI is better than any other in this respect and there is great individual variation in response
      • some SSRIs (paroxetine, fluoxetine, paroxetine, sertraline) interact with cytochrome P450, so avoid in patients on Tamoxifen
    • SSRI’s such as paroxetine (12.5-25mg daily) has shown to reduce flushes in 50%, while fluoxetine (20mg daily) has also been reported to reduce in 60% (3)
    • SNRIs (venlafaxine) (4) - dosage 37.5mg -150mg sustained release preparations recommended; baseline benefit quoted 20-66%
      • often poorly tolerated at outset with dizziness and other associated SSRI side effects including sexual dysfunction, slow titration may be the answer
      • no interaction with cytochrome P450 so may be safest choice for patients on Tamoxifen
        
        
• stellate ganglion blockade -
  • echnique involves injecting a local anaesthetic into the stellate ganglion
  • has shown to be effective against hot flushes and sweating refractory to other treatments or where HRT is contraindicated, such as in women with breast cancer (2)
    
    
• diet and supplements
  • calcium, calcitonins, vitamin D supplements, exercise - for prevention of osteoporosis
    
    
• complementary therapies
  • efficacy and safety of these preparations are lacking and some evidence suggests of possible harmful effects (1)
  • evening primrose/starflower oil (a rich source of gamolenic acid), is used for breast tenderness and mood swings
  • there is some evidence that isoflavones or black cohosh may relieve vasomotor symptoms (4)
    • however
      • multiple preparations are available and their safety is uncertain
      • different preparations may vary
      • interactions with other medicines have been reported
        
        
• psychological support (4)
  • NICE suggest that a clinican should consider CBT to alleviate low mood or anxiety that arise as a result of the menopause

Post menopausal vaginal symptoms are best treated with locally delivered low dose natural oestrogens (in the form of tablet, ring, cream or pessary) (3).

• improvement or relief of symptoms is reported by 80 to 100% of treated women
• when used at recommended doses, the increase in serum oestrogen levels is very little and addition of a progestin to protect the uterus is not necessary (3)
• nonhormonal vaginal moisturisers can be used for vaginal dryness and are available without prescription in UK (1) (oil based preparations should be avoided in women using condoms to prevent sexually transmitted diseases)

Note:

• has been suggested that therapies used to control menopausal symptoms should be reduced and then stopped to review whether it should be continued or not (1)

Reference:

• (1) Currie H, Cochrane R. Current options in the treatment of menopausal symptoms. Prescriber 2010;21(13)
• (2) Royal College of Obstetricians and Gynaecologists (2010). Alternatives to HRT for the Management of Symptoms of the Menopause
• (3) Grady D. Clinical practice. Management of menopausal symptoms. N Engl J Med. 2006;355(22):2338-47.
• (4) NICE (November 2019). Menopause: diagnosis and management
• (5) British Menopause Society. Prescribable alternatives to HRT (Accessed 12/2/2020).