Alternatives and Adjuncts to HRT (DRAFT)

Lifestyle changes

The Menopause Wellness Hub provides further information including leaflets and videos to help women make informed choices about their lifestyle Menopause Wellness Hub - Women's Health Concern (womens-health-concern.org)  

Dietary Changes – good nutrition and a balanced diet rather than purely weight loss should be the focus. The BMS has a 10 top tips for Nutrition and weight gain in the menopause 18-BMS-TfC-MenopauseNutritionandWeightGain-TopTenTips-JUNE2023-A.pdf (thebms.org.uk) 

Exercise 

• Aim for the European recommended 150/minutes of moderate intensity exercise per week  

• Stress the importance of strength and resistance exercise as part of a regular exercise routine for all women.  

• Yoga, Tai Chi and Pilates can prove beneficial for joint aches, flushes and mental health symptoms.  

Reduce alcohol intake – alcohol commonly increases hot flushes and negatively impacts sleep. Recommend women do not exceed the recommended maximum alcohol intake of 14/units per week. 

Smoking Cessation - improves bone strength, reduces the risk of heart disease and some cancers, and improves vasomotor symptoms.  

Caffeine – may increase hot flushes and can reduce sleep.  

Sleep

• Menopause is known to have a negative impact on sleep.  

• Poor sleep is often multifactorial, and all factors should be considered and managed as appropriate. 

• CBT can be helpful - See Remedy provision of services Insomnia 

• Sleep apps (e.g. Sleepio, Headspace, Unmind) have been demonstrated to be an effective management option for poor sleep in the menopause.  

• BNSSG patients can access ‘Silver Cloud’ for free, register here: Space for Sleep - SilverCloud (silvercloudhealth.com) 

CBT

NICE recommends CBT as a treatment option for anxiety and depressed mood experienced by women during the menopause transition and post menopause. 

CBT, developed specifically for menopausal symptoms, can help women to manage hot flushes and night sweats (vasomotor symptoms), and has been found to be effective in clinical trials for women going through the menopause and for breast cancer patients.  

Refer patients using local pathways (Talking Therapies (IAPT) or women can access support privately. 

Patients can also use self-help books, e.g. Managing Hot Flushes and Night Sweats: A cognitive behavioural self-help guide to the menopause – Myra Hunt, Living well through the menopause: an evidence based cognitive behavioural guide – Myra Hunt and Melanie Smith.

Acupuncture

Women often report reduction of hot flushes and night sweats with acupuncture, although clinical trials show no difference between true and sham acupuncture, the therapeutic relationship with the practitioner may also prove beneficial. A meta-analysis of the effects of acupuncture on frequency and severity of hot flushes, menopause-related symptoms, and quality of life in women in natural menopause showed a significant reduction in hot flushes and sweats.  

Acupuncture is not available on the NHS and patients should be advised to seek out practitioners registered with the British Acupuncture Society with a special interest in menopause (www.acupuncture.org.uk ) 

Patients with recent cancer may be eligible to financial support to access a course of acupuncture via Macmillan (Acupuncture | Macmillan Cancer Support) 

Over the counter options and supplements

Vitamin D (10mcg or 1000IU OD) - recommended for women in the perimenopause and menopause.  

Calcium – women should achieve the recommended daily intake of calcium (700mg per day). Those with osteopenia or osteoporosis should aim for an increased intake (1200mg per day). Patients can calculate their own calcium intake using a calcium calculator (e.g. CALCIUM - Calcium Calculator | International Osteoporosis Foundation ). This should be supplemented if intake is low.  

Supplements 

Women’s Health Concern (BMS) has produced a patient information leaflet on complementary and alternative therapies which includes advice on herbal treatments: 03-WHC-FACTSHEET-Complementary-And-Alternative-Therapies-NOV2023-C.pdf (womens-health-concern.org) 

There are many other over the counter supplements available which many women in the UK use to manage menopause symptoms. These are not always regulated, and women should be advised to use supplements with the THR logo. 

NICE advises that there is some evidence that isoflavones and black cohosh may relieve vasomotor symptoms, but the quality, purity, constituents, and safety of these products may be unknown, and different preparations may vary.  

Most herbal supplements have not been tested in patients with previous breast or oestrogen sensitive cancers and these people need to be more cautious. Isoflavones, red clover and black cohosh, vitamin E and magnetic devices are not recommended for those who have had breast cancer. For those suffering with menopause symptoms and previous cancer, please make a referral to the menopause-oncology clinic if appropriate.  

See Breast conditions and HRT and Hormone Sensitive Cancers. 

St. John’s Wort – used by some people to manage vasomotor and mood symptoms, however it has many drug interactions and must be listed in a drug history. NICE advises that the herbal preparation St John's wort may interact with other drugs such as tamoxifen, anticoagulants, and anticonvulsants. In addition, there is uncertainty about the appropriate dose, and possible variation of potency of over-the-counter preparations.

Prescribable alternatives

The British Menopause Society has produced a useful summary of prescribable alternatives to HRT – available here 02-BMS-TfC-Prescribable-alternatives-to-HRT-NOV2022-A.pdf (thebms.org.uk) 

Resources

PATIENT RESOURCES 

Menopause Wellness Hub - Women's Health Concern (womens-health-concern.org)  

17-WHC-FACTSHEET-Menopause-and-insomnia-NOV2022-B.pdf (womens-health-concern.org) 

03-WHC-FACTSHEET-Complementary-And-Alternative-Therapies-NOV2023-C.pdf (womens-health-concern.org) 

Menopause: Weight gain, nutrition and lifestyle - a British Menopause Society video (youtube.com) 

Food for healthy bones - NHS (www.nhs.uk) 

Exercise - NHS (www.nhs.uk) 

How does alcohol affect women? | Drinkaware 

Alternatives to hormone replacement therapy (HRT) - NHS (www.nhs.uk) 

19-WHC-FACTSHEET-Osteoporosis-Bone-NOV2022-B.pdf (womens-health-concern.org) 

Insomnia (Poor Sleep) (medical.azureedge.net) 

Menopause - Moving Medicine - resource to help clinicians address physical activity in routine clinical care. Specific section available on menopause.  

BMS TV - British Menopause Society (thebms.org.uk) 

REFERENCES AND RESOURCES

02-BMS-TfC-Prescribable-alternatives-to-HRT-NOV2022-A.pdf (thebms.org.uk) 

19-BMS-TfC-Menopause-Nutrition-and-Weight-Gain-JUNE2023-A.pdf (thebms.org.uk) 

01-BMS-TfC-CBT-NOV2022-A.pdf (thebms.org.uk) 

Scenario: Management of menopause, perimenopause, or premature ovarian insufficiency | Management | Menopause | CKS | NICE 

04-BMS-ConsensusStatement-Non-hormonal-based-treatments-JUNE2024-B.pdf (thebms.org.uk) 

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.