Non HRT treatments- part 1

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Non-HRT treatments for hot flushes and night sweats

Lifestyle

There is some evidence that women who are more active tend to suffer less from the symptoms of the menopause. However, not all types of activity lead to an improvement in symptoms. High-impact exercise done 'now and then' may even make symptoms worse. The best activity is regular sustained aerobic exercise such as regular swimming or jogging.

Wearing lighter clothing, sleeping in a cooler room, and reducing stress may reduce the number of hot flushes. Some women find that things such as spicy foods, caffeine (in tea, coffee, cola, etc), smoking, and alcohol may trigger hot flushes. Avoiding these things may help in some cases.

Selective serotonin reuptake inhibitor (SSRIs) - and SNRIs

SSRIs are a class of antidepressant. They include: paroxetine, fluoxetine, and citalopram. Several years ago it was noticed as a 'side-effect' that menopausal women who took these medicines for depression had fewer hot flushes. Since then, several clinical trials have confirmed that several SSRIs stop or reduce hot flushes in some (but not all) menopausal women. That is, whether they were depressed or not. A similar antidepressant drug called venlafaxine has also been shown to have this effect. Strictly speaking, venlafaxine is classed as a selective noradrenaline reuptake inhibitors (SNRI). How SSRIs and SNRIs work to help hot flushes is not clear.

When it works, an SSRI or SNRI provides relief from hot flushes almost immediately. A 1-2 week trial is usually enough to find out whether it is going to work or not. If symptoms improve, a longer course may then be prescribed.

Clonidine

Clinical trials have shown that flushing symptoms in some women can be eased by taking a medicine called clonidine. However, it frequently causes side-effects such as dry mouth, drowsiness, dizziness, and feeling sick. It is therefore not commonly used, but may be worth a try if other treatments do not help. Clonidine is thought to work by interfering with a body chemical called noradrenaline which is involved with the process of flushing and sweating.

Progestogen tablets

HRT usually refers to replacing the oestrogen hormone. Progestogen hormone has also been shown to reduce flushing in some women, although to a lesser extent than oestrogen. The risk of taking a progestogen hormone is less than taking an oestrogen hormone.

Gabapentin

Gabapentin is medicine that is usually used to control epileptic seizures and pain. However, research has shown that it may ease menopausal flushing symptoms in some women. More research is needed to confirm the place of gabapentin in the treatment of menopause.

Note: strictly speaking, SSRIs, SNRIs, progestogen tablets and gabapentin are not licensed for treating menopausal symptoms. However, many doctors are willing to prescribe one of these treatments, with the patient's consent, to see if it works.

Complementary and alternative treatments

Because of recent concerns regarding HRT, some women have turned to complementary and alternative treatments. For example, the following have been marketed for menopausal symptoms: black cohosh, red clover, dong quai, evening primrose oil, ginseng, soy, and kava.

However, just because a product is labelled 'natural' does not mean that it is automatically 'safe' and free from potentially damaging chemicals. A recent national guideline from Clinical Knowledge Summaries (reference at the end) states that "CKS does not recommend the use of complementary therapies". The reasons include:

They have not been shown convincingly to work very well.
There is very little control over the quality of the products available, which may vary considerably.
Some of these treatments (ginseng, black cohosh, and red clover) have oestrogenic properties and should not be used in women who should not take oestrogen (for example, women with breast cancer).
Long-term safety (for example, effects on the breast and lining of the uterus) have not been assessed.
Some may have serious side-effects. For example, severe liver damage has been reported with black cohosh and kava. Kava has been withdrawn from the UK market because of concerns over safety.
Dong quai and some species of red clover contain chemicals called coumarins, which make them unsuitable if you take anticoagulants (such as warfarin).

A consensus statement from the British Menopause Society (reference below) also states ...

"This guidance regarding alternative and complementary therapies is in response to the increased use of these strategies by women who believe them to be safer and more 'natural'. The choice is confusing. Evidence from randomized trials that alternative and complementary therapies improve menopausal symptoms or have the same benefits as hormone replacement therapy (HRT) is poor. A major concern is interaction with other treatments, with potentially fatal consequences. Some preparations may contain estrogenic compounds, and this is a concern for women with hormone-dependent diseases, such as breast cancer. Concern also exists about the quality control of production."