HRT can undoubtedly be transformative for those who take it, but not everyone needs — or wants — a treatment based on hormones.
Women with a history of breast cancer, as well as those at risk of blood clots or who have liver disease, may be advised against it or restricted to certain types.
Many other women may simply choose not to take HRT, preferring non-medical interventions.
And here, in the third part of our essential guide, we have listed the help of experts to examine the alternatives.
Women with a history of breast cancer, as well as those at risk of blood clots or who have liver disease, may be advised against it or restricted to certain types
These include not just natural remedies (see below right), but also drugs designed for other purposes that can tackle individual menopause symptoms, such as the blood pressure medication, clonidine.
‘Clonidine affects the dilation of blood vessels and may help alleviate hot flushes and night sweats in some women,’ says Sid Dajani, a pharmacist in Bishopstoke, near Southampton.
Possible side-effects include drowsiness or dry mouth.
Gabapentin, a drug typically taken for seizures and nerve pain, has also been used as a treatment for hot flushes. However, it can cause drowsiness, and long-term use has been linked to dependency.
Researchers are now looking at a new approach, a class of drugs known as neurokinin 3 receptor (NK3R) antagonists. These reduce symptoms such as night sweats and hot flushes by limiting activity of the neurokinin 3 receptor. The drugs, taken orally as a daily tablet or capsule, work by binding to the receptors and blocking them.
One study showed that NK3R antagonists reduced hot flushes after four weeks of treatment. By day three, hot flush frequency in the group taking the medication had already reduced by 72 per cent, and severity was down by 38 per cent, compared with those given a placebo.
Dr Nick Panay, a consultant gynaecologist with an interest in menopause and menstrual disorders, is part of a team looking into these drugs. He says that the new treatment isn’t necessarily better than estrogen therapy, but adds: ‘It will hopefully be an option for women with contraindications to estrogen, or those who don’t want to use HRT.’
‘There is some evidence that the therapy can also help with sleep, mood and quality of life,’ says Dr Panay, who is based at the Chelsea and Westminster Hospital as well as The Women’s Wellness Center in London.
He notes that advanced clinical trials are under way in a number of countries, and the treatment could be available in ‘another year or two’. Yet drugs are not for everyone, and non-medical interventions are an important part of controlling troublesome menopause symptoms, says Kathy Abernethy, the former chair of the British Menopause Society and author of Menopause: The One-Stop Guide.
‘A lot of women want to manage the menopause in a natural way,’ she adds.
Some find mindfulness and meditation effective, although the clinical data is inconclusive.
According to a review of studies published last year in the Journal of Psychosomatic Research, mindfulness may improve quality of life, but there was insufficient evidence that it reduced menopause symptoms such as hot flushes.
Cognitive behavioral therapy (CBT), however, is clinically proven to help reduce symptoms such as hot flushes and night sweats (vasomotor symptoms), low mood and anxiety.
One study showed that NK3R antagonists reduced hot flushes after four weeks of treatment. By day three, hot flush frequency in the group taking the medication had already reduced by 72 per cent, and severity was down by 38 per cent, compared with those given a placebo
Myra Hunter, an emeritus professor of clinical health psychology at King’s College London, has developed a specialized form of CBT to treat symptoms of the menopause.
She has published a number of studies in eminent journals, including Menopause and The Lancet Oncology, demonstrating its effectiveness when treating vasomotor symptoms for women going through the menopause, and for breast cancer patients.
The therapy involves face-to-face sessions, or the use of a booklet and audio plus guidance via phone or the internet. It focuses on changing negative beliefs associated with having hot flushes in public or at work, such as ‘everyone is looking at me’, which increases psychological distress and makes hot flushes worse.
It also helps women develop strategies to cope with, and reduce, stress.
‘CBT for menopause symptoms is well-researched and has a strong academic base,’ says Professor Hunter. It can also be used to tackle poor sleep, which is often associated with the menopause.
Professor Hunter’s research has shown that women who learn CBT in a group setting often get the most out of the practice, although self-help therapy, books and online resources are also effective. ‘It can be very empowering to be in a group where you can be supported and guided,’ she explains.
‘The group can also help share the message that menopause symptoms are normal and that we shouldn’t be ashamed of having them.’
CBT does require some effort and commitment — it takes around eight hours in total (either two hours a week for four weeks, or one-and-a-half-hour sessions over six weeks).
Professor Hunter says women typically report some improvements after a few sessions, and ‘our studies [showed] improvements continued six months later’.
Lifestyle changes can alleviate menopause symptoms, too — especially regular exercise. Although there have been many inconclusive studies, research published in the journal Maturitas in 2012 found that aerobic training helped to improve sleep quality and reduced hot flushes.
‘Exactly why is not known, but regular exercise can help you maintain a healthy weight, relieve stress and improve your quality of life,’ says personal fitness instructor Kathryn Freeland.
She recommends building daily exercise into your life to reap the benefits before you even reach the menopause.
‘If you are a beginner, start with ten minutes of brisk exercise a day, whether it be walking, cycling or swimming,’ she says.
She advises that women experiencing menopausal changes should choose an exercise they enjoy and then gradually increase the intensity and duration by about 10 per cent a week.
‘Perseverance is important if you are perimenopausal or post-menopausal because results happen more slowly,’ she says.
She explains that we lose muscle mass with age, and this slows down the rate at which the body burns calories, making it harder to maintain a healthy weight.
For women who are overweight or suffering from sore joints linked to the menopause, aerobic exercise such as cycling and swimming can be better than weight-loading workouts that put extra pressure on the hips and knees.
Diet is also an important non-medical way to ease symptoms of the menopause.
‘A lot of women I see in clinic are experiencing a range of unpleasant symptoms they cannot control, but their diet is something they can control,’ says Marcela Fiuza, from the British Dietetic Association and a specialist in the menopause and women’s health.
‘The healthier and fitter you are, the more able you will be to deal with the changes you are going through,’ she says.
We will take a closer look at which foods are the best to eat (and which you should avoid) in the final part of this series next week.
From maca root to sage leaf, expert guide to what works
Alternative remedies are popular because they’re thought to be natural and therefore safer.
Yet the truth is more complicated, as despite having been used in traditional medicine for centuries, alternative remedies have often not been subjected to the same scrutiny as mainstream medicines.
For instance, in 2010 a report by the Royal College of Obstetricians and Gynecologists warned that many herbal remedies had not been properly tested. The report also suggests that alternative preparations may reduce symptoms by 50 to 60 per cent, much lower than HRT, which can reduce symptoms by 80 to 90 per cent.
‘If you are going to use an alternative remedy, check with your doctors first to make sure it doesn’t interact with any medication,’ advises Dr Heather Currie, a gynaecologist and former chair of the British Menopause Society.
‘And look for products marked with a Traditional Herbal Registration (THR) symbol or product license number. This doesn’t guarantee safety or efficacy but it confirms it contains what it claims to.’
Here we look at some of the most popular alternative remedies…
Black cohosh: Made from the root of a North American plant, it comes as a powder, pill or capsule, taken two to three times a day. The Royal College of Obstetrics and Gynecologists suggests it can help reduce hot flushes for some women.
‘Black cohosh can help hot flushes in some women, though obviously it’s not as effective as HRT,’ says Dr Currie. ‘Avoid if you have liver problems, as it has been linked to liver damage. It can also react with other medications, especially medication for breast cancer, epilepsy, heart disease or asthma.’
Potential side-effects include headaches and upset stomachs.
St John’s Wort: This herbal remedy, derived from a European plant, is popular for its ability to lift low mood, but studies have found that it can improve the low sex drive that can accompany menopause. It’s thought to regulate mood by increasing the levels of chemical messengers in the brain.
‘St John’s wort can help hot flushes and night sweats and some women have found it helpful for low mood, though the evidence is limited,’ says Dr Currie.
The remedy can interact with many drugs including antidepressants, asthma drugs, oral contraceptives and migraine pills, so check with your doctor first.
Red clover: Taken as capsules or powder, red clover is derived from a plant grown in Africa and Asia and contains phytoestrogen, a plant hormone that acts in a similar way to estrogen.
A study published in the journal PLoS One in 2017 found that fermented red clover extract may help reduce the severity of night sweats and hot flushes and prevent menopausal bone loss.
However, the researchers were cautious about saying red clover works — it could be the fermentation process used to produce it that makes the difference, they said, as it allows the body to access the estrogen-like compounds in red clover.
‘Some women find this helpful for hot flushes, but again, the evidence is limited,’ says Dr Currie. ‘It’s not recommended for women who have hormone-sensitive cancer such as breast cancer.’
Evening primrose oil: The oil from the seeds of this plant, which is native to North America, is rich in gamma-Linolenic acid, an essential fatty acid involved in the production of hormone-like substances called prostaglandins. Boosting prostaglandins is thought to counter the hormonal changes associated with the menopause.
There’s little robust evidence to support its effectiveness, ‘but some women find it helps breast tenderness in particular’, says Dr Currie.