?Alternatives

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?Alternatives to HRT
Prof. Aboubakr Elnashar
Benha University Hospital, Egypt E-mail
elnashar53_at_hotmail.com
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In 1997, 42 of Americans had used 1 of 16
different alternative therapies (Gass Rebar,
2001)
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Why Alternatives to HRT are requested? 1.
Contraindication to HRT 2. Belief that HRT
interfere with nature 3. Desire to be in
control 4. Fear of long term effects of
HRT 5. Fear of adverse effects. 6. lack of
information about HRT
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Facts about alternatives for HRT 1.Most treat
only a single problem 2.There is potential harm,
because of a lack of efficacy or possible risks
3.There is a lack of evidence to confirm
benefits or possible adverse effects. 4.There is
a widespread belief that natural means
harmless, but herbs may contain potent chemicals
should be used with caution.
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Alternatives to HRT 1. Lifestyle Changes
2. Dietary changes supplements 3. Complementary
therapies 4. Drugs
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I. Lifestyle changes
1. Avoidance of trigger factors for vasomotor
symptoms. 2. Avoidance of risk factors associated
with osteoporosis.
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1. Avoidance of trigger factors for vasomotor
symptoms Alcohol, caffeine, smoking, hot or
spicy food or drinks, hot environment stress.
Good ventilation, minimal heating light bed
linen.
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2. Avoidance of risk factors associated with
osteoporosis Smoking, alcohol inactivity.
Smoking is associated with reduced bone
formation due to 1. the toxic effect of
nicotine on osteoblasts or 2. the increased
hepatic clearance of oestrogen, which in turn
will increase bone resorption.
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Excerise Effects 1. In early life maximize
bone mass later help to conserve it. 2.
Extremely important to cardiac health, helping to
reduce weight, blood pressure cholesterol
levels. Women who walked for at least 1h/w
experienced half the CHD risk of women who did
not walked. 3. Reduced incidence of severe hot
flushes, depression improve mood.
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Type Regular Weight bearing. The safest
excerise is walking (30 minute 4-5 times /week.
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II. Dietary changes
I. Multivitamins. II. Minerals. III. Natural
hormones.
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I. Multivitamins 1. Vit E 400-1200 IU daily a.
Reduces VM symptoms (Kass-Annesse,2000) b.
Reduces the risk of CHD (100 IU daily for 2
years) The Nurses health study, 1993). Low
level of Vit E is a better predictor of CHD than
elevated cholesterol or blood pressure (Cooper et
al,1994)
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2. Vitamin D 400 IU daily with calcium
significantly reduced fracture risk (Chapuy et
al, 1992) Oily fish eaten at least twice a week
reduced mortality from CHD (Daviglus et al,
1997) Garlic reduction of cholesterol is
doubtful (Daviglus et al, 1997)
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• II. Minerals
• Adequate calcium intake 1500 mg daily reduction
  of hip fracture (Cumming et al, 1997).
• Adequate intake of magnesium is crucial for
  osteoporosis prevention (Kass-Annesse,2000).
• The dietary ratio of calcium to magnesium is best
  maintained at 21.

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• Avoid factors increasing urinary calcium loss
• . High sodium intake
• . High phosphorus (soft drinks such as cola)
  may be damaging for young bone (Carey Carey,
  1999).
• . High protein intake, generally in the form of
  animal protein (Nordin, 2000).
• . High caffeine intake is associated with an
  increase in fracture

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III. Natural hormones 1. Phytoestrogens Asian
women experience fewer menopausal symptoms than
western women their traditional diet contain
high level of phytoestrogens, about 200 mg daily
compared with lt 5 mg daily in western diet.
Derived from plants
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Types 1. Isoflavones soya beans (richest
source), chick peas, lentils 2. Lignans apples,
stone fruits, onion, garlic, seed oils, cereals,
fruit vegetables. 3. Coumestans clover
Available in tablet (Klimadynoncimicifugae) f
ood supplements in bread, snack bars, health
drinks.
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Activities oestrogenic, anti-oestrogenic,
depending on target tissue endogenous levels of
sex hormones (Tham et al,1998) antiviral,
anticarcinogenic, bactericidal, antifungal,
antioxidant, antimutagenic, antihypertensive,
anti-inflammatory, antiproliferative effects.
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Effects 1. Reduction of menopausal symptoms
Prevention of osteoporosis data are conflicting.
2. FDA has approved food substances containing
soy protein to reduce the risk of heart
disease. Adverse effects No adverse
effects Risks No randomized studies. So, it is
not possible to draw absolute conclusions
without large long-term RCT.
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2. Natural progestagen creams Extracted from
plant source, mainly yams soya. Effects An
improvement in vasomotor symptoms but no effect
on bone (DTB, 2001)
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3. Dehydroepiandrosterone (DHEA) Available as a
food supplement. Effects improved mood, sleep,
tiredness ability to cope (Thaker Booher,
1999). Adverse effects lowering HDLP,
increasing insulin resistance raising blood
pressure
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III. Complementary therapies
1. Herbalism. 2. Acupuncture. 3. Stress
reduction. 4. Homoeopathy.
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• There are over 100 therapies
• Limited evidence to support their efficacy or
  safety (Brockie, 2002).
• May help with the short term problems not the
  long term.

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1. Herbalism There is a widespread belief that
natural means harmless, but herbs may contain
potent chemicals should be used with caution.
There is a number of known drug-herb
interactions. In Germany, herbs are classified
as drugs regulated by Commission E
(Blumennnthal,1998).
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A. Black cohosh (Cimmicifugae racemosae) Effective
in alleviation of vasomotor symptoms, insomnia
low mood (Mckenna et al, 2001). Daily dose 40
mg no longer than 6 months. No drug
interaction.
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B. St John s Wort (Hypericum) Dose 900 ug daily.
Effective in reducing flushes, low mood,
insomnia (Grube et al, 1999). Drug interactions
include theophylline, digoxin, cyclosporin,
combined oral contraceptive pills.
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.Valerian, sage, chste tree, dong quai, ginseng,
gingko biloba, kava, garlic, feverfew
Comission E does not recommend them for use at
menopause (2002) because of Limited scientific
data or adverse side effects. .Oil of evening
primrose in a placebo RCT is not effective
(Chenoy et al, 1994) .Chinese herbs are not
effective in placebo RCT (Davis et al, 2001)
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2. Acupuncture Significant reduction in
vasomotor symptoms the benefits continued for 3
weeks (Wyong et al, 1995 Tukmachi, 2000).
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• 3. Stress reduction
• Encouraging women
• to reassess their priorities in life,
• to reduce unnecessary stress that in turn may
  alleviate some symptoms.
• Relaxation excerises were found to decrease the
  number of hot flashes.

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Simple deep breathing periodically through-out
the day for approximately 1 minute reduces hot
flashes up to 50 (Wijma et al, 1997). Support
groups for menopausal women To overcome the
feeling of isolation.
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• 4. Homoeotherapy
• A comprehensive system of medicine based on the
  principle of like cures like relying on the use
  of a highly diluted solution of a substance. High
  concentrations of a substance may induce symptoms
  of the disease, where as the same substance in a
  highly diluted solution may treat the disease.
• It has many sceptics, although as an alternative
  treatment, it is safe.
• RCT are needed to clarify its value in the
  menopause.

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Aromatherapy (the use of smells, pleasant
unpleasant to induce certain health benefits,
relaxation or emotions), massage reflexology
No scientific evidence to show any benefit on
menopausal symptoms. They are helpful in stress
reduction.
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IV. Drugs
I. For prevention treatment of osteoporosis II.
For treatment of vasomotor symptoms III. For
symptomatic treatment of atrophic vaginitis
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Many are effective but only for single
problem. I. For prevention treatment of
osteoporosis 1. Bisphosphonates 2. Raloxifene
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II.For treatment of vasomotor symptoms 1.
Antidepressants For hot flushes. Also positive
effect on mood libido, Adverse effects dry
mouth, nausea, constipation, reduced appetite
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Paroxetine (seroxat) (20 mg daily) 67 reduction
in hot flushes (Stearns et al, 2000) Venlafaxine
(Efexor) (75 mg daily) 61 reduction (Loprinzi,
2000) (RCT). The benefits are seen within a
couple of weeks. Venlafaxine 37.5 mg daily 37
reduction of hot flushes fewer adverse effects
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2. Night sedation For insomnia mood swings 3.
Veralipide (agreal) 100 mg daily for 20 days,
repeated after 7 days. It is neuroliptic 4.
Propranolol No data to support its use (Brockie,
2002)
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5.Bellergal-Retard phenobarbitone (central
sedative 40 mg), belladona (parasympathetic
inhibitor, 0.2 mg), ergometrin tartarate
(sympathetic inhibitor, 0.6 mg) one tab twice
daily 6. Clonidine (catapress) 0.1 to 0.2 mg
twice daily Rarely used because 30 reduction
which is little different from placebo (Laufer,
1982) 7.Gabapentin (Guttuso, 2000). (Uncontrolled
study)
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III. For symptomatic treatment of atrophic
vaginitis 1. Simple vaginal lubricants
Astroglide, Lubrin, replens 2. Long acting
bioadhesive vaginal moisturiser It is
comparable to vaginal estrogen preparation
(Nachtigal,1994). It is a gel containing water
polycarbophil that adhere to the vaginal wall,
encouraging water back into the dehydrated cells.
Each application lasts for about 3 days.
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3. Vaginal estriol or estradiol It is not
absorbed systemically to any significant degree.
They can be used safely in .women with a
contraindication to systemic estrogen . in a
long term without any effect on the breast or
endometrium (Brockie,2002).
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Conclusions
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1. Alternative therapies can offer treatment
options to women who either have a
contraindication to HRT or who prefer to avoid
it. 2. Alternatives to HRT are associated with
potential harm, because of a lack of efficacy or
possible risks 3. Most alternatives treat only a
single problem
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4. There is a lack of evidence to confirm
benefits or to highlight possible adverse
effects. 5. Alternatives to HRT include
Lifestyle changes, dietary changes supplements,
complementary therapies alternative drugs. 6.
Prtocol of Oxford Menopause Clinic, 2002.
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Thank you
Prof. Aboubakr Elnashar
Benha University Hospital, Egypt E-mail
elnashar53_at_hotmail.com