The majority of women experience a natural menopause (sometimes called the ‘change of life’) when their periods finish, usually around the age of 51 years. During the years when women are having periods, the ovaries produce eggs and the female hormones estrogen and progesterone. As women approach the menopause, there are few remaining eggs in the ovaries and those that remain are less likely to develop. Fewer eggs are released and less of the hormones are produced, until the ovaries finally stop working and periods stop. Often the menopause is accompanied by uncomfortable symptoms. These symptoms are caused by fluctuating and lower levels of estrogen.
In a recent survey 95% of women said they would try alternative therapies before HRT because they think they are more natural and because they are worried about the health risks of HRT. NICE guidelines have used carefully weighed evidence-based evaluations of the effectiveness of alternative treatments compared with placebo (no treatment) and also with conventional forms of HRT.
Women should receive an individualised approach at all stages of their care, to help them make decisions based on the evidence given to them. Healthcare professionals are tasked with providing an explanation of the stages of the menopause and women should receive an explanation about what to expect. These include changes in the menstrual cycle and the symptoms which may be experienced such as hot flushes and night sweats, musculo-skeletal problems, mood changes (different from depression), uro-genital symptoms and sexual difficulties. There will be changing symptoms at different stages and this too needs to be recognised.
Your clinician should help you explore the lifestyle changes which will improve your general health and well-being and explore the long-term implications of the menopause. They should be able to provide information about the different treatments including the benefits and risks of treatments and the evidence for their effectiveness.
Women who have breast cancer or are at high risk of breast cancer should receive care and advice from a healthcare professional with expertise in the menopause.
Many women will elect to take no treatment for their symptoms, some do not wish to take hormones and for others HRT is not advisable.
NICE use some different techniques to measure the effectiveness of different therapies. A network meta-analysis (NMA) allows lots of different treatments to be compared by how well they worked in relation to another treatment. An NMA compared placebo (no treatment) acupuncture, sham acupuncture, oestrogen alone, estrogen and progestogen, non-oral estrogen plus progestogen, tibolone, gabapentin, Selective Serotonin Reuptake Inhibitors (SSRI) and Selective Norepinephrine Reuptake Inhibitors (SNRI), Isoflavones, Chinese herbal medicine, black cohosh, multi botanicals and cognitive behavioural therapy (CBT) all with each other which provided the evidence for the 2015 NICE Menopause Guidelines.
One of the powerful messages coming from the NICE Guidelines is that herbal remedies which are not regulated by a medicine authority should not be considered safer, as there is much variety in their effectiveness and potency and that there may be significant side effects. The same warning is given for bio-identical hormones which are compounded and again not regulated or subject to quality control.
Complementary and alternative treatments
Cognitive behavioural therapy (CBT)
The good news is that CBT can alleviate low mood and anxiety which arise as a result of the menopause, and now we realise CBT can also improve hot flushes and sweats. The North American Menopause Society (NAMS) recommends a CBT approach that combines relaxation techniques, sleep hygiene and learning to take positive healthy attitude to a menopause challenge. CBT is now a recommended treatment option for anxiety experienced during the peri and post-menopause. A CBT approach which is theory based can improve hot flush perception and reduce stress and sleep problems. There are two-way interactions between mood and hot flushes as 10% of women are more likely to be depressed during the menopause. A fact sheet (written by Professor Myra Hunter, Kings College London) on the Women’s Health Concern website provides guidance on cognitive behavioural therapy in a self-help format for women to access directly.
Guidelines recommend that you look for the THR logo standing for traditional herbal medicines. These products have been approved and you can be sure that the product has the correct dosage, is of high quality and has suitable product information. The NICE guidelines also recommend that many available herbal medicines have unpredictable dose and purity and some herbal medicines have significant drug interactions.
This North American traditional herb can help hot flushes although not as well as HRT. Black cohosh does not help with anxiety or low mood, but black cohosh can interact with other medicines and there are unknown risks regarding safety.
St John’s Wort:
Again the good news is that St John’s Wort was shown to have benefit in relieving vasomotor symptoms, particularly in women with a history of, or at high risk of breast cancer. However, like black cohosh, it does interact with other drugs which again makes it a drug we have concerns about, including its reliability regarding dose effectiveness and safety profiles. Women on tamoxifen must not take St John’s Wort as it makes the tamoxifen ineffective.
Other herbal treatments including Ginseng and Chinese herbal medicines are not shown to improve hot flushes, anxiety or low mood.
Isoflavones and soya products (plant substances found in the diet including red clover supplements)
Phytoestrogens (isoflavones) can form a large part of dietary intake in certain ethnic groups; these women should continue their normal diet. There are very many studies looking at the effectiveness of these food substances, but the results are variable and generally show little value. They are not recommended in patients with breast cancer.
Women often report reduction of hot flushes and night sweats with acupuncture, although clinical trials disappointingly show no difference between true and sham acupuncture, (sham acupuncture is when the patient receives needling, but not into true acupuncture points). It is likely this is due to a high placebo effect associated with acupuncture therapy.
Non hormonal prescribed treatments
Selective Serotonin Re-uptake Inhibitors (SSRI) [fluoxetine, paroxetine, citalopram, sertraline] and the Serotonin Noradrenaline Re-uptake Inhibitor/Selective Serotonin Re-uptake Inhibitors (SSRI-SNRI) [venlafaxine].
Historically SSRI and SNRIs are recognised for their effects on depression and anxiety, and some of these medicines can improve hot flushes in some women. Paroxetine 10 mg seems to be the most effective, even at low doseage and is now a recognised (licensed) treatment for menopausal hot flushes in the USA. Other SSRIs which may be helpful include citalopram and fluoxetine. Venlafaxine is also an option and is the preferred treatment for breast cancer survivors taking Tamoxifen and at 75mg there can be reduction in hot flushes with improvement in fatigue, mental health and sleep disturbance. SSRIs and SSRI/ SNRIs can have associated significant side effects, such as dry mouth, nausea, constipation and appetite problems which are commoner at higher dosage, and reduction in libido is often experienced, a very unwanted extra effect for menopausal women. SSRIs should not be offered for vasomotor symptoms unless HRT cannot be given. Those women taking tamoxifen should not take fluoxetine or paroxetine, as again it makes the tamoxifen ineffective.
Gamma aminobutyric acid (gabapentin):
Gabapentin can improve flushes and sweats. Side effects include sleepiness, dizziness, weight gain and dry mouth and increase with higher dosage. A small dose is commenced and increased gradually, according to the effect on symptoms and side effects. Some patients like this medication as it improves sleep, but others find it very sedating in the day as well. Since April 2019 both gabapentin and pregabalin must be prescribed as controlled drugs (schedule 2) which imposes restrictions on the prescriber.
Clonidine is the only non-hormonal drug licenced for use for hot flushes in the UK. Clonidine 25mcg is prescribed twice daily for 2 weeks, increased to a maximum of 50mcg three times a day. Studies of its effectiveness are contradictory although a few women may have significant benefit. At higher doses clonidine causes sleep disturbance in at least 50 percent of users. It must be withdrawn gradually as suddenly stopping it can cause rebound high blood pressure. As it is an anti-hypertensive drug, clonidine may not be suitable for patients with a baseline low blood pressure.
Treatments for breast cancer survivors
Most women diagnosed and treated for breast cancer will live with their cancer, rather than die from it. More research is needed into the safety of possibly using estrogen-based therapies for some of these women, particularly in receptor negative patients, but for the moment most clinical guidelines will not recommend estrogen based treatments. The North American Menopause Society (NAMS) looked for solid evidence of a few therapies that work so as not to waste patients’ time experimenting with things that really don’t work. NAMS recommends SSRIs, SNRIs, Gabapentin, Pregablin, Clonidine, CBT and clinical hypnosis. The UK NICE guidelines (November 2015) indicate that SSRIs, SNRIs and Gabapentin are no better than placebo and that Paroxetine and Fluoxetine will reduce the efficacy of Tamoxifen. For breast cancer survivors, one NICE guideline recommends Clonidine, Venlafaxine and Gabapentin might be tried, although the NICE 2015 Guideline indicates that only St John’s Wort may improve symptoms, although not recommended because of serious drug interactions.
Isoflavones, red clover and black cohosh are not recommended for breast cancer survivors by any of the International bodies.
A recent trials of the neurokinin 3 receptor agonist fezolinetant indicates that we have hopeful anticipation of a safe new non hormonal agent which works within a few days to reduce vasomotor symptoms. Neurokinin 3 receptor agonists are currently only available in the research setting, but all the indications are that it will be a valuable agent for those who cannot use hormonal therapies.
It is important to recognise that all this information is “evidence-based”, which means it is not hearsay or factoid, but supported by powerful scientific evidence.
Few complementary and alternative treatment options have proven evidence of effectiveness, but although many options do not stand up to scrutiny from a robust and evidence-based perspective, there will be individual women who will benefit from some of these treatments.
It is most important to have an individualised approach from your practitioner. We are realising more and more that the powerful placebo effect from almost every menopause intervention (which can be at the 50-60 percent level) may be due to improved brain chemical messengers which are generated because you believe that the treatment option will be effective.
Your healthcare professional should help you pick through the different treatment options to help identify which ones may be the best for you. This guidance is evidence based, not individualised and it is possible you might be one of the two percent who responds extremely well to one or more of these alternatives. You should ask to discuss any ongoing issues with a menopause specialist.
British Acupuncture Council
63 Jeddo Road , London, W12 9HQ
Tel: 020 8735 0400
British Reflexology Association
Monks Orchard, Whitbourne, Worcester WR6 5RB
Tel: 01886 821 207
This fact sheet has been prepared by Women’s Health Concern and reviewed by the medical advisory council of the British Menopause Society. It is for your information and advice and should be used in consultation with your own medical practitioner.
Author: Jane Woyka in collaboration with the medical advisory council of the British Menopause Society.