Non hormonal options for menopausal symptoms

There are a variety of non hormonal approaches to managing menopausal symptoms. Many women find these sufficient to alleviate their symptoms.

Lifestyle approaches

• Dress in layers such that when a hot flush occurs you can easily discard a layer and then layer up when it has passed
• Carry a small fan (many women find this very useful)
• Avoid factors that might bring on a flush, such as smoking, alcohol or caffeine
• Although increasing physical activity, stress management and acupuncture are each often recommended as ways to reduce symptoms, firm evidence to support their benefits specifically for hot flushes is lacking

Non hormonal drug therapies

Various prescribed and over-the-counter therapies are used to reduce menopausal symptoms. Although many of these therapies have not been found to be any more effective than placebo therapy (dummy therapy) in clinical trials, women often report a benefit. This is usually due to what we call the ‘placebo effect’.

What is the placebo effect?

This is an improvement in symptoms when taking a specific treatment that in fact has no medicinal benefit (eg sugar tablets), because the person taking the therapy believes it works. It may also be because the person taking the therapy also alters their behaviour in other ways at the same time, such that the changed behaviour (such as eating less cheese) is the reason for the improvement experienced (eg: lower cholesterol). The placebo effect is seen in a wide range of medical situations ranging from reduction in chronic pain through to reduction in hot flushes. In fact in clinical studies placebo therapy usually results in between a 30 to 50% reduction in hot flushes. For a medical treatment to be considered effective it has to be substantially more effective than a placebo.

Clonidine

Women who flush appear to have greater sympathetic nervous system activity and the drug clonidine, originally developed to treat blood pressure (as a centrally acting α-adrenergic stimulating agent), may act by elevating the “flush threshold”.

Clonidine 50 to 150 mcg twice daily has been used for many years to alleviate hot flushes with some effectiveness. Some women experience side effects at very low doses (dry mouth). In general, most women do not find clonidine useful.

Selective serotonin reuptake inhibitors (SSRIs) and SNRIs

SSRIs are commonly taken to reduce hot flushes and improve mood disorders in women either preferring not to or unable to use hormone therapy. Venlafaxine (37.5 to 75mg) and paroxetine (7.5 to 25 mg per day) can be quite effective. Both therapies may cause nausea and insomnia. In addition, venlafaxine may cause dry mouth, constipation and decreased appetite whereas paroxetine may cause headeaches.

Of note, paroxetine should not be used in combination with tamoxifen, as it may impair conversion of tamoxifen to its active form, endoxifen, by inhibiting the liver enzyme CYP2D6 (P4502D6) and thus interfering with its effectiveness as an anti-cancer agent.

The effect on flushes appears to be independent of the effect on mood, with relief from hot flushes occurring from the first week of use whilst the antidepressant effect usually takes about 6-8 weeks to occur. The lowest effective dose should be used and when ceasing the drug the dose should be slowly tapered.

Gabapentin

Gabapentin was developed for the treatment of epilepsy. It is also used for neurogenic pain, restless-leg syndrome, essential tremor, bipolar disorder and migraine prevention. Doses of 300-900mg at night have been shown to be effective in reducing the frequency and severity of hot flushes. As gabapentin can be slightly sedating it is best taken at bedtime.

Phytoestrogens

Plant constituents with a molecule structure similar to estrogen are known as phyto (plant) estrogens. These compounds, found in a wide variety of edible plants, may display both estrogen-like and anti-estrogenic effects. Initially studies comparing Asian and Western women were interpreted to indicate that eating a phytoestrogen-rich diet may reduce menopausal symptoms and may protect against breast cancer, bone loss and heart disease. Consequently increased consumption of phytoestrogen rich foods (soy and flaxseed etc) became very popular and tablet formulations of concentrated phytoestrogen (isoflavone) extracts were heavily promoted.

A number of large studies evaluating the effects of phytoestrogen supplements on hot flushes have now been conducted. Most of the findings from these studies do not support a role for phytoestrogens for the treatment of menopausal symptoms. The effects of phytoestrogens on the breast remain unclear.

Black cohosh

Black cohosh (Cimicifuga racemosa, also known as Actaea racemosa) is a North American native plant. It has common usage internationally for the treatment of hot flushes and sweats experienced by postmenopausal women. Overall, results of quality clinical research trials do not show black cohosh is useful in the treatment of hot flushes. However, results differ between trials.

There have been several case reports linking black cohosh to acute hepatitis requiring liver transplant after a few weeks of treatment. Women considering the use of black cohosh should have their liver function checked by blood testing before starting this herb and periodically during treatment. Safety beyond 6 months is unknown as are the clinical effects of black cohosh on the breast.

Other over-the-counter therapies

Many dietary supplements are promoted for prevention of menopausal symptoms. These often include a variety of vitamins and minerals and sometimes various herbs. There is no evidence that such supplements prevent hot flushes and night sweats or other symptoms of menopause. Although women may experience benefit this is usually due to a placebo effect.

Chinese herbs may or not be effective as inadequately studied; acupuncture has been found to be no more effective than placebo and neither yoga or exercise have been found to reduce hot flushes.