1. HRT – so what are the alternatives? NICOLA HILLS Swindon/Bath GP Registrar DRC December 2005

2. Why? Recent research raised concern re HRT Explosion in alternatives available Internet full of herbal remedies What remedies do you recommend doctor?

3. Aims Overview of alternatives to HRT Know your black cohosh from your dong quai……..

4. Menopause Average age 51. >9 million postmenopausal women in UK Perimenopausal transition period lasts 4 yrs on average Symptoms due to low oestrogen Vasomotor instability affects 75%, 25% severely.

5. Hot flushes (60% experience,most common symptom), sweats, headaches, tiredness, irritability, poor memory, sleep disturbance, depression, anxiety, loss of libido, dry skin, vaginal atrophy, osteoporosis…..

6. HRT Very effective at treating symptoms of menopause. Until recent studies (Women’s Health Initiative and Million Women Study), widely used for long periods

7. Since media reports of recent studies, over 70% American women and 50% British women stopped HRT. Due to recurrence of symptoms, many keen to or have already restarted HRT. But are there any alternatives?

8. Medical alternatives to HRT Progestogens eg norethisterone can help control vasomotor symptoms, but can increase risk of TED. SSRIs eg venlafaxine, paroxetine, for hot flushes. New finding, only small studies. Gabapentin can also help relieve hot flushes

9. Clonidine can help flushes, common side-effects of dry mouth, drowsiness, dizziness and nausea limit use. Bisphosphonates/SERMs for osteoporosis Vaginal lubricants and topical oestrogens for vaginal dryness etc Lifestyle – exercise, reduce stress, avoid spicy foods, caffeine and alcohol

10. Complementary therapies Little evidence to support use but many women use them, ‘safer’ ‘more natural’. Little known re active ingredients, safety, side-effects, interactions, and contaminants. Phytoestrogens and herbal remedies used.

11. Phytoestrogens Plant substances that have effects similar to oestrogen. Bind to oestrogen receptors, acting like hormone regulators. Most important groups are isoflavones and lignans. Isoflavones found in soybeans, chick peas, red clover, and other legumes. Oilseeds like flaxseed, bran, whole cereals, vegetables, legumes and fruit contain lignans.

12. Observation made that populations with diets high in them eg Japanese have lower rates of menopausal symptoms, CVR disease, osteoporosis and many cancers. Studies small, lack power and use different methodologies. One review, only 3 out of 12 RCTs reduced hot flushes.

13. Red clover Perennial herb, abundant in UK Use flower head Been used to treat whooping cough, gout, eczema and cancers Contain isoflavones 3,570,000 sites on Google. £11.99 for 100 capsules at Holland & Barrett!

14. Thought to have anticoagulant properties, so should avoid use with warfarin. Overall, evidence shows not better than placebo at controlling hot flushes, but widely used in UK.

15. Black Cohosh aka black snakeroot, bugwort. Member of buttercup family. Widely used by Native Americans for colds, arthritis, malaria, sore throats, female infertility, labour pain and miscarriage. Formulations inc tablets, capsules, liquid and tincture.

16. Remifemin most widely used product. Used a lot in Germany. 40mg BD dose often used. Large doses can cause dizziness, slow HR, headaches, joint pain and uterine contractions 1,950,000 sites on Google

17. 90 capsules £6.89 at H&B, currently 50% off! Debate over whether contains phytoestrogens Seems to have more positive evidence than others. However formulation and regimen vary between studies.

18. No evidence that is safe to use if have breast cancer, so should avoid. More rigorous studies are underway

19. Dong quai Chinese herbal medicine Grows in China, Korea and Japan Use dried roots, can be used as tonic, tincture or in capsules Also used for constipation, PMS, and anaemia. Often used in combination with other herbs

20. 870,000 sites on Google £8.99 for 100 capsules at H&B, currently 50% off! Only one published RCT, no better than placebo in reducing menopausal symptoms Shouldn’t use with warfarin, can also cause rashes, ? cancers

21. Kava Traditional ritual tranquilising beverage from the rootstock of a plant of the pepper family, native to Vanuatu. Used for ceremonial purposes, as a symbolic welcome for VIPs, beverage for culminating the marriage ceremony, a relaxant and to ? treat UTIs! ? help mood during menopause

22. Serious hepatic side-effects have been reported though eg hepatitis, cirrhosis and liver failure. Prohibition order regarding medicinal products containing kava came into force Jan 2003. 1,870,000 sites on Google

23. Others Evening primrose oil, vitamin E, American ginseng, wild yam, sage and St. Johns wort are also used, no controlled studies on their effects on menopausal symptoms.

24. Conclusions Still a role for HRT, assess patients symptoms and risk. Short-term use <5 yrs, lowest oestrogen dose and regular reviews. Further evidence re HRT safety emerging.

26. Need further quality research into complementary therapies. Most evidence for Black cohosh, but preparations/doses vary. Vast amount of misleading info on net

27. Useful websites www.menopausematters.co.uk www.the-bms.org