Transcript Slide 1

HRT – so what are the
alternatives?
NICOLA HILLS
Swindon/Bath GP Registrar DRC
December 2005
Why?
Recent research raised concern re HRT
 Explosion in alternatives available
 Internet full of herbal remedies
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What remedies do you recommend
doctor?
Aims
Overview of alternatives to HRT
 Know your black cohosh from your dong
quai……..
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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.
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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…..
HRT
Very effective at treating symptoms of
menopause.
 Until recent studies (Women’s Health
Initiative and Million Women Study),
widely used for long periods
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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.
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But are there any alternatives?
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
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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
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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.
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Phytoestrogens
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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.
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.
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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!
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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.
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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.
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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
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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.
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No evidence that is safe to use if have
breast cancer, so should avoid.
 More rigorous studies are underway
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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
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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
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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
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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
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Others
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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.
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.
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Need further quality research into
complementary therapies.
 Most evidence for Black cohosh, but
preparations/doses vary.
 Vast amount of misleading info on net
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Useful websites
www.menopausematters.co.uk
 www.the-bms.org
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