Alternatives to HRT 

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When a large clinical trial found that combined hormone replacement therapy (HRT) increased the risk of invasive breast cancer, strokes, heart attacks and blood clots, many menopausal women decided to investigate alternative options (1). This factsheet will provide women with information about alternatives to HRT. It discusses lifestyle changes that may be beneficial for women reaching menopause as well as some of the more common alternatives women are choosing to use. A separate factsheet, About Menopause, is also available.

Lifestyle changes

A natural approach to menopause should ideally involve a complete lifestyle approach, incorporating dietary changes, exercise and stress management strategies. Menopause is a perfect time for women to evaluate these aspects of their lives and make changes to ensure they stay healthy, now and in the future.

Nutrition
Having a healthy diet is one of the most important components. There are a number of dietary changes that are beneficial.

Heavily refined or processed foods (eg., take-away meals, convenience foods) should only be eaten occasionally as they are often high in salt, sugar or saturated fats. Diets high in these substances have been linked to obesity and an increased risk of cardiovascular disease and diabetes. It is also helpful to limit foods which cause a rapid rise in blood sugar levels (eg., white bread products, cake, soft drink, sweets and stimulants like tea, coffee, alcohol and chocolate). Fluctuating blood sugar levels can result in symptoms often attributed to menopause; tiredness, irritability, difficulty concentrating and anxiety (2).

Improving one’s diet can be achieved through choosing more whole foods; foods close to their natural state. Women should aim to eat plenty of fresh fruit and vegetables and complex carbohydrates. Complex carbohydrates (wholegrain breads, grains and beans/pulses) are broken down more slowly in the body and, therefore, keep blood sugar levels more stable. Low fat dairy products, fish, lean meat and healthy fats (olive oil, canola oil, nuts and seeds) should also be included. It is best to eat a variety of foods from each of the different food groups. Having a varied diet allows us to benefit from the nutrients provided by different foods.

Another important consideration is the intake of calcium as it plays a role in preventing osteoporosis. The recommended daily intake of calcium for Australian women is
1 000mg, increasing to 1 300mg for women over the age of 50 (3). Foods high in calcium include dairy products (low fat products are as beneficial as full cream), canned fish with bones (sardines/salmon), soy products with added calcium, almonds, dried figs and dark green leafy vegetables (Chinese greens, spinach). A deficiency of Vitamin D can impair calcium absorption. The majority of women in Australia , however, should receive sufficient Vitamin D from sun exposure (15 minutes on the face, hands and arms daily).

The quantity of food eaten is also important as the body’s metabolism slows with age and, therefore, a person requires less energy. If women continue to eat the same amount and expend the same energy as before they will experience a gradual weight gain. To address this, women can monitor overall energy intake and portion sizes and avoid ‘empty calorie foods’, those high in calories but low in nutrients.

Exercise
An exercise program should include a combination of aerobic, weight-bearing, strengthening and flexibility exercise. Aerobic exercise increases the heart rate which provides protection from cardiovascular disease and assists in maintaining a healthy weight. Examples include jogging, walking, swimming or cycling. Weight-bearing exercise is exercise that is “done on your feet so the force of gravity acts through the skeleton” (4). It helps to maintain bone mass, therefore, preventing osteoporosis and includes jogging, walking, tennis and netball.

Strengthening exercise works muscles against resistance, such as weight training. This exercise can also have a positive impact on bone mass. Flexibility exercise mobilises and stretches joints, ligaments, muscles and tendons and includes yoga and pilates. This exercise can help prevent falls and conditions like arthritis. Activities which involve more than one type of exercise (eg., walking is both weight-bearing and aerobic) are ideal.

Exercise affects the levels of hormones and chemicals in the body. For example, exercise increases the level of endorphins, the brain chemicals responsible for feelings of happiness. Exercise has been proven to be an effective treatment for mild to moderate depression and anxiety. Exercise also helps stabilise the body’s blood sugar levels, boosts metabolism and improves sleep.

Some tips for starting an exercise regime include:

• choose a range of activities that include the four different types of exercises
• start slowly and gradually build up the activity level - it is advisable for those       who have not participated in regular exercise for a period of time to first have a       physical examination by a doctor
• always perform warm up and cool down exercises and stretches to reduce the       risk of injury and post-exercise soreness or stiffness
• to keep motivated choose activities that are enjoyable, exercise with others or       keep an exercise diary
• incorporate exercise into everyday routines such as getting to and from work,       taking the stairs instead of the elevator, walking or cycling to the shops       instead of driving.

Stress management strategies
Stress is a necessary aspect of our lives; it provides motivation and stimulation. When we are under stress the adrenal glands produce the hormone adrenaline, causing an increase in respiration, heart rate and blood pressure. This automatic physiological response prepares the body to respond to an immediate threat or danger (referred to as the fight or flight response). Stress becomes a problem when people experience it, and the physiological reactions it produces, too frequently. The repeated stimulation of the adrenal glands, for example, can interfere with their proper functioning. This is something that should be avoided as these glands are an important source of oestrogen production after menopause. Other symptoms of stress include stomach upsets, headaches, sleeping difficulties, muscle tension and a reduced immune system.

A person’s individual coping mechanisms play a large role in their experience of stress. There are a number of strategies that people can learn to assist them in coping with stressful situations. For example, people can learn to change negative or distorted thinking patterns by reading one of the many self-help books available or by consulting a therapist. It is also helpful for people to identify what they find stressful so that practical attempts can be made to reduce the occurrence of such situations.

Stress for women can often be attributed to juggling multiple roles. Reducing the number of demands, therefore, is an important part of stress management. Prioritising tasks and eliminating those that are unnecessary or infeasible can reduce the stress associated with feeling overwhelmed. Effectively managing time by planning ahead and being organised at home and/or work can also reduce levels of stress.

There are also activities that women can participate in which relieve stress. These include massage, yoga, relaxation/meditation, Tai chi and regular exercise.

Popular alternative treatments for menopause

In the majority of cases, scientific studies supporting the effectiveness and safety of alternative treatments for menopause are limited. Much of the evidence demonstrating a benefit comes from small uncontrolled trials, unpublished research or is anecdotal. It is important that alternative treatments are trialled as menopausal treatments are known to have a large placebo effect. That is, many women will have a positive reaction based on their expectation of a benefit rather than from any property of the treatment itself. Trials are also needed to determine recommended dosages, length of treatment and the safety of alternative treatments. Women should always inform their doctor if they are using alternative treatments for the relief of menopausal symptoms.

Dietary phytoestrogens
Phytoestrogens are naturally occurring compounds found in plants which produce a weak oestrogenic effect. When there is a deficiency of oestrogen, as occurs in menopausal women, phytoestrogens bind to the empty oestrogen-receptor sites. There are three types of phytoestrogens – isoflavones, lignans and coumestans – with isoflavones being the most common. Linseed, soy beans and soy products (milk, tofu, tempeh and miso) have been found to be the richest sources of phytoestrogens (5). However, phytoestrogen levels can vary greatly depending upon plant variety, time of harvesting, growing conditions and processing methods.

The optimal intake of dietary phytoestrogens appears to be between 30-50mg day (6). The differences in the phytoestrogen content of products makes recommending daily food choices to achieve an adequate phytoestrogen intake difficult. As a rough guide, the phytoestrogen content of some foods are:

• 250ml soy milk – 15-60mg
• 115g block tofu – 13-43mg
• 2 slices of soy and linseed bread – 7-15mg
• 200g tub of tofu yoghurt – 26mg
• 1 tablespoon of soy grits – 25-32mg (7).

Evidence – The benefits of dietary phytoestrogens in menopause have been largely based on studies comparing the experiences of Asian women (who have a diet high in phytoestrogens) with Western women (who generally have a diet low in phytoestrogens). It is reported that Asian women experience fewer menopausal symptoms, such as hot flushes. It is, however, problematic to suggest that such a difference is based solely on the intake of phytoestrogens as other factors could be involved; for instance a cultural difference in how women express menopausal symptoms (8). There is currently little scientific evidence to suggest that dietary phytoestrogens reduce hot flushes more than a placebo (9).

Bioidentical hormones
These hormonal preparations require a doctor’s prescription and are made up by compounding chemists. They come in the form of lozenges, troches, creams, pessaries and tablets. Preparations are said to be tailor-made for each individual, often based on the results of saliva or blood tests. Advocates of bioidentical hormones claim that because they are closer in structure to the hormones found in the body they have less side effects than HRT. Bioidentical hormones may contain oestrogen, progesterone, testosterone, DHEA, thyroxine, growth hormone and melatonin (10).

The term ‘bioidentical’ is somewhat misleading as it suggests to women that the hormones are ‘natural’ when in fact they are synthetically produced in a laboratory. Bioidentical hormones are currently not regulated in the same way as pharmaceutical drugs and, therefore, there is less quality control over aspects like dosage and purity. Bioidentical hormonal preparations are also more expensive than HRT as they are not available through the Pharmaceutical Benefits Scheme (PBS).

Evidence – There are few scientific studies supporting the effectiveness of bioidentical hormones for menopausal symptoms, with most evidence being anecdotal. There is also limited data on the safety and/or side effects of the preparations. Little is known, for example, about the safety of the combinations or dosages of the ingredients they contain. Of particular concern is that the progesterone contained in some bioidentical hormonal preparations may be insufficient to protect the uterus (oestrogen administered on its own can cause cancer of the uterus) (11). A decision to take bioidentical hormones, therefore, should be made with the knowledge that these hormonal preparations pose similar or possibly higher risks than HRT.

Wild yam cream
Wild yam cream is said to have hormone balancing properties, assisting with menopausal symptoms like hot flushes. Some manufacturers claim that their product either contains progesterone or can increase progesterone levels in the body. This is incorrect as products containing progesterone are only available on prescription. Similarly, the human body is not capable of converting the ingredients in wild yam (eg., diosgenin) to progesterone.

Evidence – There is currently no quality evidence to support the use of wild yam cream in relieving menopausal symptoms (12).

Herbal medicine
In menopause, herbal medicine is used to both influence hormonal changes as well as treat individual symptoms. Herbal medicine is administered in a number of forms including extracts, infusions, capsules, tablets and creams.

Herbs such as black cohosh, vitex agnus castus, dong quai and maca are used for their hormone balancing properties. Other herbs like ginseng and licorice are used to ensure the optimal functioning of the adrenal glands. Herbs used in the treatment of individual symptoms include sage (night sweats and hot flushes), valerian and hops (insomnia) and calendula and evening primrose oil (vaginal dryness).

Although herbal remedies are natural they contain powerful ingredients and, therefore, need to be taken with the same care as other medicines. Women interested in using herbal medicine are advised to consult a qualified health practitioner for an individualised assessment and consultation.

Evidence – While there is some evidence to support the effectiveness of black cohosh in treating hot flushes, further studies are needed (13) (for more information on black cohosh see the Non-prescription supplements section below). There is little evidence to support the use of other herbs in the treatment of menopausal symptoms.

Non-prescription supplements
Women’s interest in alternatives to HRT has seen a boom in supplements claiming to relieve menopausal symptoms. The more popular non-prescription supplements include:

Phytoestrogen (isoflavone) supplements – These products contain extracts of either soy or red clover. They are predominantly promoted as reducing hot flushes. Results from trials suggest that isoflavone supplements may produce a slight to modest reduction in hot flushes but this is most likely to occur in women who experience frequent and severe flushes (14). As the long term safety of phytoestrogen supplements has not been established they are not recommended for women with a history of breast cancer (15, 16). Women taking these supplements should be careful to follow the recommended dosage.

Black cohosh supplements – These supplements are predominantly promoted for reducing hot flushes. Studies of black cohosh supplements for menopausal symptoms have produced conflicting results. A study of 340 women reported a benefit but other smaller studies have found the supplements to be no better than a placebo (17). Further studies are required. The Therapeutic Goods Administration require products containing black cohosh to carry the following warning: “Black cohosh may harm the liver in some individuals. Use under the supervision of a healthcare professional” (18).

Others – Other popular non-prescription supplements consist of a combination of herbs and/or vitamins and minerals. The concern with these supplements is that they may not contain enough of any one ingredient for them to be effective or that the safety of combining particular ingredients is unknown.

Prescription medications

Since the risks of HRT were revealed, there has been an interest in the use of other prescription medications to relieve menopausal symptoms like hot flushes. Several medications, including antidepressants, hypertension drugs and epilepsy drugs have been trialled for treating hot flushes. However, further studies are required (19).

References

1  Writing Group for the Women's Health Initiative Randomized Controlled Trial. Risks and benefits of estrogen plus progestin in healthy postmenopausal women JAMA 288;3:321-33
2 Glenville, M. Natural Alternatives to HRT London: Kyle Cathie, 2002; 63
3  National Health and Medical Research Council. Nutrient Reference Values for Australian and New Zealand, Including Recommended Dietary Intakes Canberra: NHMRC, 2005; 158
4 Rose, L. Osteoporosis: The Silent Epidemic Sydney: Allen and Unwin 1994; 178
5 Howes, L. Isoflavone phyto-oestrogens Medical Observer March 5 1999 Update p1-3
6 Lyons-Wall, P. A nutritional perspective on soy phytoestrogens for menopausal women- controversies, uncertainties and practicalities Health Journey Vol 1 2002 p1-4
7 Lyons-Wall, P. Ibid
8 Howes, L. Ibid
9 Nedrow, A et al. Complementary and alternative therapies for the management of menopause-related symptoms Arch Intern Med 2006 166;1453-1465
10 MacLennan AH and Sturdee DW. The "Bio-identical/Bioequivalent" hormone scam (editorial) Climacteric 2006; 9:1-3
11 MacLennan AH and Sturdee DW. Ibid
12 Nedrow, A et al. Ibid
13 Low Dog T. Menopause: a review of botanical dietary supplements Am J Med 2005; 118:12B:98S-108S
14 Howes LG, Howes JB and Knight DC. Isoflavone therapy for menopausal flushes: A systematic review and meta-analysis Maturitas 2006; 55:203-211
15 The Cancer Council of New South Wales. Position Statement: Soy, Phyto-estrogens and Cancer http://www.cancercouncil.com.au/html/healthprofessionals/nutrition_physical/
downloads/ posion_statement_soy_n_cancer.pdf [website] date accessed January 25 2006.
16 Herbal Medicines Research and Education Centre. Herbs used in menopause Complementary Medicine 2004; 4:50-56
17 Nedrow, A et al. Ibid
18 Therapeutic Goods Administration. Black Cohosh (Cimicifuga racemosa): New Labelling and Consumer Information for Medicine Containing Black Cohosh (February 2006) http://www.tga.gov.au/cm/blkcohosh.htm [website] date accessed: December 12 2006.
19 Carroll DG. Nonhormonal therapies for hot flashes in menopause Am Fam Physician 2006; 73:3:457-64

Further help and information from Women's Health Queensland Wide

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Our free statewide line is staffed by women's health nurses and midwives. They provide women with up to date information, support and referral to health practitioners and services. Women can contact the Health Information Line by phone or email via the 'Ask a Health Question' page on the website. All phone calls and emails are confidential.
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Library:
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Website:
All our factsheets and booklets are available on our website. The website also features articles on women's health from our newsletter, student factsheets, upcoming events, library services and 'Ask a Health Question' page. A list of reputable links is also available where women can search for further information on health topics.
www.womhealth.org.au

Further reading/viewing

• About menopause factsheet
• Middle years library booklist
• Weight management issues for women over 40 videostream
  

This factsheet was originally published in December 1997. It was revised by Kirsten Braun and the Editorial Committee in October 1999, January 2003 and January 2007.

Last Modified: January 31, 2007