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Freedom of choice: alternatives to HRT

Janet Brockie
Menopause Nurse Specialist
John Radcliffe Hospital

Many women are reluctant to take hormone replacement therapy since the publication of recent studies, and they want information on alternative therapies at the menopause.(1,2) Generally women have to be motivated to succeed with these approaches, and they may not be as effective as HRT.
However, HRT is still advised for young women up to 51 years of age with a premature menopause, for cardiovascular disease and osteoporosis protection, and for women with distressing symptoms.(3)
Rethinking the role of healthy life habits and attitudes is of increasing importance for symptom control and long-term protection against cardiovascular disease and osteoporosis.(4)
Diet is one factor that may explain the cultural differences in the menopause experience. Asian women experience fewer menopausal symptoms and their traditional diets contain higher levels of phytoestrogens. These are weak oestrogens found in plants, structurally similar to oestradiol, which is the main premenopausal oestrogen. Isoflavones and lignans are thought to be the significant phytoestrogens at the menopause. Isoflavones are found in legumes and the soy bean. Lignans are found in seed oils, cereals, fruit and vegetables.
The evidence that phyto­estrogens reduce menopause symptoms is conflicting. Some studies have certainly shown that they reduce vasomotor symptoms, have a mild oestrogenic effect on the vagina and have a beneficial effect on cholesterol and triglycerides, but they may take several months to have an effect.(5)
They are certainly worthy of more research, particularly their effect on bone. They are not advised for women with a history of breast cancer. Studies have not shown any adverse effects from phytoestrogens; they are well tolerated and, despite their cost, they remain a very popular supplement.
Vasomotor symptoms
It is well known that there are trigger factors for vasomotor symptoms. These include alcohol, caffeine, smoking, obesity and current weight gain, hot or spicy food and hot drinks, together with a hot environment and stress. Women reporting premenstrual symptoms, depression, perceived stress and chronic disease were likely to flush more, whereas women with higher or postgraduate education, in fulltime employment and who exercised vigorously were likely to have fewer.(6) The benefit of exercise on weight also has advantages for vasomotor symptoms.(7) A high body mass index (BMI; >30) is associated with an increased risk of moderate and severe hot flushes in premenopausal and perimenopausal women.
Women may have to change the way they dress, with layers of clothes that can be easily removed and then replaced after the flush. Good ventilation, minimal heating and light bed linen may help.
Studies showing the effect of vitamins date back to the 1940s, with varying results. Anecdotal evidence suggests that multivitamin and mineral supplements can reduce flushes, but the effect is prorbably geater if the initial diet is poor.

Psychological symptoms
Encouraging women to reassess their lives, to reduce unnecessary stress and to increase exercise may help these symptoms. Reducing flushes and night sweats may improve insomnia, tiredness and low mood. The menopause in the Western world is frequently viewed as a time of changing role and purpose in life and even entry into old age. Women who are negative about the menopause are more likely to have psychological problems. A pilot study highlighted the value of support groups for menopausal women, to overcome the feelings of isolation as well as serving as an education and support function.(8)
Exercise can reduce depression and improve insomnia, together with providing a greater feeling of wellbeing; it protects against cognitive decline in the elderly.

Urogenital symptoms
Seventy per cent of women relate the onset of incontinence to the menopause. Pelvic floor exercises can provide significant improvement to both stress and urge incontinence as long as they are performed properly over a prolonged period of time.
Remind women of the diuretic effect of caffeine and alcohol. Smoking and obesity also increase the risk of developing incontinence.
Sexual activity declines in both sexes with ageing for many reasons. Reduced arousal, loss of libido or vaginal atrophy may be associated with the menopause. Education will help women adapt their sexual behaviour to accommodate some of these changes.(9) Regular sexual activity is important for maintaining sexual function. Improving other menopause symptoms such as vasomotor symptoms and low mood may also improve sexual activity. Over-the-counter vaginal lubricants can reduce dyspareunia caused by atrophic vaginitis.

Several diet and lifestyle risk factors are associated with osteoporosis. A high alcohol intake and smo, animal protein and phosphorus (from fizzy dking will adversely affect bone density. Caffeine, saltrinks) are all harmful in excess. Exercise throughout life is important to bones, in early life to maximise bone mass and later to help conserve it. It is also effective in slowing the gradual long-term ageing-related bone loss. Exercise needs to be specifically geared to each individual with respect to their weight. The safest to recommend is walking. A recent study showed that one hour of daily outdoor walking, of at least 8,000 steps, four times a week over 12 months demonstrated a positive effect on lumbar bone density measurements.(10)
Calcium alone is not sufficient to prevent bone loss in postmenopausal women but avoiding a negative calcium balance will prevent accelerating the loss. In the postmenopause, women not on HRT are recommended to include 1,500mg of calcium daily, adding vitamin D if a woman has poor exposure to sunlight.(5)

Cardiovascular disease (CHD)
Women who walk for at least one hour each week halve their CHD risk compared with nonwalkers. More active women are less likely to smoke, more likely to consume alcohol, eat less saturated fat, more fibre and more fruit and vegetables. They have less hypertension, less risk of diabetes and lower cholesterol. Exercise is significant for weight control. A group of obese women aged 50-75 years took part in an exercise trial, losing significant amounts of weight. Greater weight loss was associated with an increasing duration of exercise.
A high intake of fruit and vegetables reduces cardiovascular disease and some cancers. Oily fish is significant in reducing mortality from coronary heart disease, due to omega-3 fatty acids, which may have a role in the prevention of thrombosis, reducing blood pressure and triglycerides and improving insulin sensitivity. Current UK recommendations are to consume at least one portion of oily fish per week and at least five portions of a variety of fresh fruit and vegetables daily.(11)

Complementary and alternative medicine (CAM)
Using CAM is a costly but popular alternative. There is no scientific evidence to show any benefits of aromatherapy, hypnosis, yoga, traditional Chinese herbs or massage on menopause symptoms. Some may be helpful in stress reduction, and this can have a knock-on benefit on other symptoms. They are unlikely to have any effect on the long-term consequences, except through helping with lifestyle changes. Many women self medicate, and it is important to question women directly on their use of over-the-counter products to recognise side-effects and prevent drug interactions.

About 80% are still unlicensed, although with recent European legislation this will be changing. Herbs may contain potent chemicals, and caution should be used. Women with a contraindication to HRT, such as a history of breast cancer or venous thromboembolism, need to be discouraged from using them. There are known drug-herb interactions, and women should not take both herbs and pharmaceutical drugs without advice.
Black cohosh (cimicifugae racemosae) has most data to support its use. Clinical studies of black cohosh have shown it improves vasomotor symptoms, insomnia and low mood, but not in women taking tamoxifen. Apart from one report of hepatotoxicity, its safety profile is good. A daily dose of 40-80mg for six months is recommended. No drug interactions are known.
Other herbal remedies often recommended include St John's wort, valerian, sage, chaste tree, dong quai, ginseng, Ginkgo biloba, kava, garlic and feverfew. Scientific data on the effectiveness of these is limited, and there is concern about side-effects or drug interactions.
Oil of evening primrose is commonly taken by menopausal women, but in a double-blind placebo-controlled study it did not have any effect on flushes.(11)
It reduced flushes in women with previous breast cancer, including those taking tamoxifen, with the benefit remaining for three months after the treatment.(12)

This is one of the most frequently used CAMs, and anecdotally women report a beneficial effect, but the only study investigating this did not show that reflexology offered any benefit.

This is sometimes available on the NHS, and remedies are available for self-treatment. One study showed homeopathy significantly reduced symptoms, including vasomotor symptoms, fatigue and mood disturbances, in women with a history of breast cancer.(13)

Prescribed alternatives
Other prescribed medication may be a possible treatment option. Progestogens such as norethisterone 5mg or megestrol acetate 40mg daily have been shown to be effective in the control of hot flushes, and SSRIs have been shown to provide short-term improvement in flush symptomatology.(5)
Local vaginal oestriol and oestradiol preparations are not absorbed systemically so can be safely prescribed to women with a contraindication to systemic HRT to treat vaginal atrophy or lower urinary tract symptoms. Alternatively, a long-acting vaginal lubricant gives effective symptomatic relief for atrophic vaginitis and is available on prescription.(5)
Skin creams containing natural progesterone or dehydroepiandrosterone (DHEA) are available via websites. There are limited data to support their use.

Many women are unable to achieve the required amounts of calcium from their diet, and calcium supplementation is often necessary. Depending on the estimated average daily intake of calcium, adults will generally need to be prescribed calcium 500-1,000mg and vitamin D 400-800iu daily. Other bone treatment options are beyond the remit of this article.

The severity and reporting of menopause symptoms varies enormously worldwide. The association between the hormone changes and symptoms is complex and influenced by many factors. More understanding of the cause of vasomotor and psychological symptoms would undoubtedly be helpful in developing effective alternatives to HRT. In addition, adopting a healthy diet and lifestyle in early life is significant for maintaining health into old age.


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