Alternatives to HRT: Supplements & Natural Solutions for Hot Flushes, Fatigue & Other Menopause Symptoms

For many women, hormone replacement therapy (HRT) can provide much-welcome relief from the menopause’s many symptoms. But it isn’t for everyone.

As a treatment, HRT is associated with some slight increased risks. For some women — particularly those with a history of breast cancer, of blood clots, of liver disease or of untreated high blood pressure — HRT can be unsuitable.

Some women may find HRT to not be worth it considering the impact of their menopause symptoms, or may just simply want to explore a natural remedy or supplement for keeping their symptoms in check.

Let’s take a science-based look at the latest evidence for the best HRT alternatives for menopause symptoms.

Hormone replacement therapy and the menopause: why might an alternative be more suitable for me?

Hormone replacement therapy is a treatment that involves replacing oestrogen and progesterone, two female sex hormones that decline in production during the menopause.

Oestrogen and progesterone are usually taken together in a treatment called combined HRT. Some women, such as those with a hysterectomy, will usually be recommended an oestrogen-only course of HRT.

HRT has been scientifically proven to help alleviate the many symptoms women experience during the menopause — hot flushes, mood swings, vaginal dryness, fatigue and sleeping difficulties.

However, the treatment is associated with a number of slight risks that may make some types of HRT unsuitable for women with certain health issues, including those with:

• A history of breast, ovarian or womb cancer
• A history of blood clots
• A history of liver disease
• Untreated high blood pressure

Some women don’t find their menopause symptoms to be sufficiently bothersome to warrant HRT and any increased risks that come with it. Other women may simply be interested in pursuing a natural solution or remedy, seeking an alternative source of relief from their menopause symptoms.

The decision on whether to choose HRT is one for each individual woman which should be made in consultation with your doctor. You may find it helpful to take an evidence-based overview of the benefits and risks of HRT.

Fortunately, there are a number of alternative sources of relief from menopause symptoms that don’t include HRT.

What are the HRT alternatives for menopause treatment?

From lifestyle adjustments and dietary changes to alternative therapies and a number of types of medication, there are still ways to manage menopause symptoms that don’t include HRT.

Let’s explore the evidence for the effectiveness of HRT alternatives.

Lifestyle

Healthy lifestyle choices have been shown to help improve many of the classic menopause symptoms.

Mindfulness & breathing

Stress — or, rather, the absence of relaxation — is a major contributor to the aggravation of menopause symptoms, a particular trigger for hot flushes and sleeplessness. Research shows that mindful, deep breathing plays a role in making us feel relaxed, and therefore minimising menopause symptoms like hot flushes.

• One study of menopausal women showed a ‘significant reduction’ in menopausal symptoms after having performed deep breathing exercises compared to a control group.
• In one randomised 9-week study, paced breathing was shown to reduce menopause symptoms like hot flushes by inducing relaxation. As well as being simple and convenient, the most helpful ‘dose’ of paced breathing was twice per day.
• One study of 30 women found that deep breathing was helpful in the reduction of menopausal symptoms, notably hot flushes and sweating.
• In an overview of 18 clinical trials, researchers state that ‘mind-body therapies may be beneficial for alleviating specific menopausal symptoms’.

Breathe in through your nose for two seconds, then hold it for three seconds. Then, slowly exhale through your mouth for four seconds.

The best part — mindful breathing is a free, practical and easily-learned technique that can be deployed whenever you feel a hot flush coming on.

Quitting smoking

Ditching the cigarettes is not only scientifically shown to minimise hot flushes, but also drastically reduces your risk of heart disease, strokes and cancer.

• Research has found that moderate smokers are at an increased risk of moderate-to-severe hot flushes, increasing depending on the amount smoked.
• A scientific overview concluded that quitting smoking improves women’s well-being during the menopause transition, decreasing the risk, severity and frequency of hot flushes.
• One study confirms that cigarette smoking is associated with hot flushes, but with the precise mechanism yet to be confirmed.

For many women, excessive amounts of drinking are known to trigger common menopause symptoms. Some women also find that certain types of food are also associated with increased likelihood of experiencing hot flushes — particularly spicy foods.

Keeping cool

Hot flushes are probably the quintessential menopause symptom. As well as quitting smoking and practicing mindful breathing, there’s another obvious lifestyle change that can help you to minimise their impact on your life — taking steps to keep cool.

This can include lightweight clothing, particularly at night, when hot flushes become ‘night sweats’, interfering with and wreaking havoc on our sleep. These can be offset by keeping a spray bottle of cool water next to your bed, ensuring your bedroom is well ventilated and by sleeping in loose, lighter-weight clothing.

Exercise

It won’t come as a surprise to learn that regular physical activity can lift our mood and help us manage our weight, but it can also represent an effective way of combating some of the menopause’s most common and troublesome symptoms: bone density loss, hot flushes and sleeping problems.

Taking up aerobic exercise

There is evidence to suggest that menopausal women who are more active are less likely to experience vasomotor symptoms (hot flushes and night sweats), insomnia, low mood and anxiety. This should not necessarily be ultra high-impact activity, though — research shows that the best results can be from sustained, moderate intensity aerobic exercise, such as jogging, swimming or cycling.

• In a randomised controlled trial, women who performed aerobic training for six months reported decreased incidence of night sweats, irritability as well as an improved mood compared to the group who did not.
• In another study, although women did not have significant improvements in their vasomotor symptoms, those who performed moderate intensity aerobic exercise saw notable improvements in sleep quality, insomnia and depression.
• In one study of 42 women, resistance and aerobic exercise was found to have a ‘positive impact on menopause symptoms, psychological health, depression and quality of life’.

Practising yoga & tai chi

Depression, anxiety, low mood, irritability and bone loss are serious symptoms that many women report as a result of the menopause. There is a growing body of evidence to suggest that low-impact activities like yoga and tai chi can have a real effect on relieving these symptoms.

• In a recent overview of 13 randomised trials with a total of 1306 participants, yoga was shown to be an effective method for reducing hot flushes, somatic, psychological and urogenital menopause symptoms.
• In one breakthrough study, tai chi was shown to be effective at delaying bone loss in menopausal women.
• An overview of trials into the effectiveness of tai chi was more cautious, but acknowledged that the activity may have benefits on bone health in menopause-age women. It called for further research.

Weight-bearing, resistance & strength exercise

The menopause process brings with it an increased risk of bone density loss and osteoporosis — research shows that incorporating some regular weight-training and weight-bearing exercises can help to keep you in tip-top musculoskeletal shape.

• A progressive strength-training program was found to be effective at increasing bone density over two years, with strength training recommended as a lifestyle approach for menopausal women for osteoporosis prevention.
• In a randomised trial, the squat exercise was found to increase bone mineral content in the lumbar spine and femoral neck, improving the skeletal properties of postmenopausal women.
• In another study, weight-bearing exercise played a ‘vital role’ along with medication in the treatment of osteoporosis after the menopause.

Diet

A healthy, balanced diet

A varied and nutrient-rich diet is important for people of all ages, but it can become even more essential for menopausal women. For our mental, physical and musculoskeletal health, the benefits are all-encompassing.

A good diet can help women manage the increased risk of weight gain during menopause. We also know that the risk of osteoporosis grows in menopausal women, too — a healthy diet can offset this, as well as giving our mood a lift.

• In a trial of 17,473 women, healthy dietary modification helped to eliminate hot flushes and night sweats. This involved controlled weight loss through reduced fat intake and increased consumption of fruit, vegetables and whole grains.
• Adherence to common dietary recommendations — such as low fat and sugar and a high consumption of plant-based foods — is connected to a reduction in menopause hot flushes.

Watching your caffeine intake

As a stimulant, caffeine is well known to promote hot flushes in many women. Cutting back on the volume you drink, or eliminating coffee and tea entirely, has been suggested as a way of reducing the frequency, duration and intensity of vasomotor symptoms that menopausal women experience.

Managing alcohol consumption

Excessive consumption of alcohol is linked to weight gain and low mood, which many women begin to struggle with as they enter the menopause — this can be reason enough to moderate your intake.

However, the direct impact of alcohol on menopause symptoms like hot flushes is hotly debated. Some studies have shown that alcohol consumption may actually help hot flushes, but other women have noted that it can aggravate such symptoms. In one study, daily alcohol consumption was associated with more vasomotor symptoms.

If alcohol seems to be a hot flush trigger for you, consider taking a look at your intake.

Complementary and alternative therapies

The market for alternative and complementary treatments for menopause symptoms has grown rapidly in recent years.

Whilst there is evidence pointing towards the effectiveness of certain alternative herbal remedies for menopause symptoms, such research is not extensive, with uncertainty about how long any benefits may last.

There is additional uncertainty about optimal dosage for treating menopause symptoms. A 2016 article stresses that there is ‘no reliable proof’ that herbal options can alleviate menopause symptoms, with potential for side effects and interactions if taken with certain drugs.

Although these products are marketed as ‘natural’, there’s also no guarantee about the quality and purity of ingredients. These products are not licensed for menopause symptom treatment.

That said, there is some interesting evidence in favour of complementary and alternative therapies — so let’s take a look.

Black cohosh

Cimicifuga racemosa, more commonly known as black cohosh, is probably the longest-established complementary and alternative medicine for managing menopause hot flushes. It has been used for centuries in women’s health.

Black cohosh is understood to work similarly to serotonin, inducing feelings of relaxation and keeping our body temperature in check. Derived from a plant in the buttercup family, black cohosh can be mixed with water or taken as a tablet or pill.

• Evidence for the effectiveness of black cohosh is encouraging, but there are calls for more research into standardised preparations.
• In one randomised clinical trial of 301 women, women who took black cohosh and St John’s wort reported a 50 percent decrease in their symptoms on the Menopause Rating Scale, compared to 19 percent for the placebo group.
• In a randomised, double-blind, placebo-controlled trial of 84 women, those who took a daily dose of 6.5 mg of dried extract of Black cohosh roots saw improved vasomotor, psychiatric, physical, and sexual menopause symptoms.
• Another trial saw improvements in a group treated with black cohosh and St John’s wort compared to a placebo group.
• One study found that black cohosh was effective at improving quality of life and reducing the severity of hot flushes.

Side effects of black cohosh can include gastrointestinal problems and rashes. Some studies have flagged up instances of liver damage resulting from black cohosh, prompting warnings for women who have liver or autoimmune diseases, as well as calls for clearer labelling about hepatotoxicity on packaging.

As ever, be sure to have a discussion with your doctor if you’re considering black cohosh.

St John’s wort

When it comes to hot flushes, mood swings and sleeping problems during the menopause, this herbal remedy is one of the favourites. It is derived from the dried leaves and flowers of the wild Hypericum perforatum plant.

It can be mixed into a tea, consumed as a liquid or taken as a pill. Best known as a herbal antidepressant, there is some evidence that St John’s wort can improve menopause symptoms, particularly hot flushes. St John’s wort extract contains phytoestrogens — oestrogen-like plant compounds — that are thought to explain its effectiveness.

• A clinical trial of 100 women concluded that St John’s wort was ‘an effective treatment’ for hot flushes and night sweats in menopause-age women, reducing their frequency, severity and duration.
• In a 12-week treatment of one 900mg tablet taken three times per day, women experiencing menopausal symptoms reported ‘substantial improvement’ in their vasomotor, psychological and psychosomatic symptoms. Notably, treatment with St John’s wort extract improved sexual well-being.

There are calls for more structured research into the effectiveness of this plant for menopause symptoms.

As with many complementary medicines, the quality of purity of products can vary. St John’s wort is also known to interact with the effectiveness of some drugs. Make sure to consult with your doctor before deciding to start any new complementary and alternative medicines for your menopause symptoms.

Evening primrose oil

Primrose oil is another oft-touted herbal complementary and alternative medicine. There is some research attesting to the impact of evening primrose oil on hot flushes, although at present this isn’t as compelling as for other types of complementary treatment, nor is the evidence particularly extensive.

One study found evening primrose oil to be effective at improving quality of life and reducing hot flushes, but less effective than other complementary medicines like black cohosh.

In a 6-week randomised trial of 56 menopausal women, oral evening primrose oil appeared to reduce the severity of hot flushes, with some minor improvement for their frequency and duration.

As mentioned, complementary remedies like evening primrose oil are not regulated by a government agency. Therefore, it’s harder to be sure about the quality, safety and purity of ingredients.

Soy-based products

Soy products contain plant-based oestrogens called isoflavones. There is some evidence suggesting that isoflavones can reduce the intensity and frequency of hot flushes, with the effect scaling up with strength of product.

• In a review of literature, isoflavones reduced hot flushes, in addition to attenuating bone mineral density loss. According to the authors, the safety of soy-based products, coupled with their benefits, makes them a ‘compelling treatment option for women unwilling or unable to take hormone replacement therapy’.
• A 12-week study of menopausal women taking 100mg soy isoflavones reported improved Menopause Rating Scale scores, with treatment most effective at relieving bodily and psychological symptoms.
• One overview of studies reported impressive results for the alleviation of hot flushes in women taking isoflavones, particularly genistein-rich isoflavone supplements.

There are calls for more standardised research and bigger sample sizes in future studies about isoflavones and menopause symptoms. When taking isoflavones, side effects like stomach and bowel problems are not uncommon. Be sure to consult your doctor before beginning any treatment.

Ginseng

For over five thousand years, humans have used this interesting little herb for its therapeutic benefits. Ginseng is thought to be a natural ‘energiser’, most commonly consumed as part of a herbal tea, although can also be taken as an extract or powder.

Some studies report that ginseng can alleviate menopausal symptoms, with others pointing towards benefits for sexual arousal and hot flushes.

However, such evidence on the effectiveness of ginseng for the treatment of menopause symptoms is, as the authors of a scientific review put it, ‘limited’. They called for more rigorous studies in order to draw firm conclusions, highlighting that many of the clinical studies that currently exist have a high level of bias.

Vitamin D

We all know about the benefits of vitamin D for our bones, teeth and immune system function. As we age, our ability to absorb this crucial vitamin declines, which has made it particularly important for menopausal women to ensure they’re getting enough.

Although not a complementary medicine as such, there is some evidence pointing towards the importance of vitamin D specifically for menopause symptoms like osteoporosis.

• In menopausal women at risk of osteoporosis, there is often an inadequate level of vitamin D. Supplementation offers scope for the prevention of bone fracture.
• One review suggests that a sufficient level of vitamin D in menopausal women is important for bone, cognitive and cardiovascular health, with a lack of the vitamin thought to aggravate menopause-related discomfort and disease.
• However, another piece of research found no clinically important relationship between vitamin D levels and hot flushes, sleep disturbance and emotional well-being.

Getting your daily recommended dose of vitamin D can be as simple as taking a short 15–20 minute walk, or supplementing with a vitamin D capsule. You may also want to increase your intake through certain foods.

Foods that are high in vitamin D:

• Salmon
• Cod liver oil
• Red meat
• Eggs
• Liver
• Canned tuna
• Mushrooms
• Fortified dairy products

Acupuncture

Some women have found a solution to their hot flushes and night sweats by turning to acupuncture, perhaps one of the most traditional forms of complementary or alternative medicine.

Although evidence is mixed and some researchers point towards the placebo effect, a number of studies have highlighted this ancient Chinese medicine’s potential to alleviate troublesome menopause symptoms.

• In a meta-analysis of 12 randomised controlled trials, acupuncture improved the frequency and severity of menopause symptoms like hot flushes in women experiencing natural menopause, with effects lasting for up to three months.
• Another overview suggests that acupuncture can have a positive impact on menopause hot flushes and sleep problems, with clinical benefits appearing after only a few acupuncture sessions (and persisting after treatment was stopped).
• Acupuncture produced a ‘clinically relevant reduction’ in moderate-to-severe menopause symptoms, with no severe adverse effects noted.

Tibolone

As a once-a-day tablet, this is a type of medication that works in a similar way to hormone replacement therapy.

The most common brand name for tibolone is Livial. Tibolone has been clinically shown to reduce common menopause symptoms such as hot flushes, osteoporosis, mood swings and lower sex drive.

However, like HRT, can be associated with a slight increased risk of breast cancer, as well as having some occasional side effects during the first few weeks of use. This may make the medicine unsuitable for women who were concerned about the risks associated with HRT.

Benefits of tibolone for menopause symptoms:

• Hot flushes: Tibolone has been shown to relieve vasomotor symptoms like hot flushes and night sweats. Other research has confirmed this effect on hot flushes, but suggests that tibolone is less effective than HRT.
• Vaginal dryness & sexual responsiveness: As well as assisting with dryness, tibolone has been shown to improve sexual well-being and mood, with benefits for libido.
• Insomnia: Women treated with tibolone showed a ‘positive trend compared to the placebo’ when it came to sleep quality. The advantages of tibolone for menopause symptoms are not as well researched as those of HRT. Although the benefits of tibolone are promising, an overview of 46 clinical trials flagged up the ‘low or very low quality’ of available research.

Side effects of tibolone (Livial) for menopause symptoms include:

• Acne
• Increased hair growth
• Stomach and pelvic pain
• Breast tenderness
• Itching
• Slight vaginal discharge
• Breakthrough bleeding and spotting

As with HRT, side effects of tibolone usually subside after the first few months of use.

Risks of tibolone (Livial) for menopause symptoms can include:

• Breast cancer: The Million Woman Study found that there was an increased risk of breast cancer in women who took tibolone, at a similar level to those who took oestrogen-only HRT. However, the risk is reportedly lower than taking combined HRT. Other studies have reported contrasting results, finding that tibolone reduced risk of breast cancer.
• Womb cancer: Research has suggested an increased risk of endometrial cancer in women who take tibolone, with the association stronger with a longer period of use.
• Strokes: The LIFT study found that there was a 2.2 times increased risk of a stroke in women who took tibolone. Risk increased from the first year of treatment. For combined HRT users, this risk is 1.3 times.

Research currently available does not suggest that there is an increased risk of blood clots or coronary heart disease as a result of taking tibolone. Be sure to discuss the benefits and risks with your GP if you think tibolone (Livial) may be a suitable HRT alternative for your menopause symptoms.

Antidepressants

Antidepressant medicines have been shown to have a positive impact on hot flushes and have been recommended as an alternative to HRT. There are two types of antidepressant commonly used for menopause symptoms:

• Selective serotonin reuptake inhibitors (SSRIs): These are a class of antidepressant medicine that include paroxetine, fluoxetine, escitalopram and citalopram.
• Serotonin and noradrenaline reuptake inhibitors (SNRIs): A similar type of antidepressant medicine to SSRIs, which includes venlafaxine (more commonly known by the brand name, Effexor).

When these medicines first began to be used for depression, it was noted that menopausal women were seeming to have fewer (and less intense) episodes of hot flushes. SSRIs and SNRIs appear to minimise hot flushes in some, but not all menopausal women.

In one study, treatment with venlafaxine resulted in a significant improvement in menopause-related quality of life for women with vasomotor symptoms, with other research also noting ‘good results’ when antidepressants were used for menopause-related hot flushes. It is thought that the medicine balances levels of the neurotransmitters serotonin and norepinephrine, which helps to stabilise body temperature.

When taken, SSRIs and SNRIs seem to work almost instantly, so you’ll know fairly quickly whether you’re someone who responds positively to their use for hot flushes. There have been calls for more research into the effectiveness of antidepressants compared to oestrogen.

Be aware that there are known to be side effects for taking antidepressants for menopause symptoms:

• Nausea
• Decreased libido
• Decreased sexual responsiveness

Although the link has been demonstrated, it’s worth noting that these antidepressant drugs are not licensed for use for menopause symptoms. If you think antidepressants may help you, be sure to consult with your doctor to discuss the benefits and risks.

Gabapentin

Gabapentin is a drug traditionally taken for nerve pain and in order to control epilepsy. Several reports have attested to the benefits of gabapentin for reducing hot flushes. It has gained particular popularity as a non-hormonal alternative to HRT.

Benefits of gabapentin for menopause hot flushes:

• In a clinical trial of 100 menopausal women, a daily dose of gabapentin 300mg was suggested to be useful for relieving hot flushes when HRT is not suitable.
• An analysis of seven randomised controlled trials concluded that gabapentin was successful in reducing the frequency, duration and intensity of hot flushes. Authors noted that the medicine could be used to treat hot flushes in women who are unsuitable for HRT. However, they noted that the lowest possible dose should be identified in order to minimise adverse effects.
• Another study concluded that gabapentin could be added to a list of ‘non-hormonal agents for the control of hot flashes’. The beneficial effects of gabapentin for menopause symptoms take around two weeks to show.

Side effects of gabapentin for menopause can include:

• Dizziness
• Nausea
• Fatigue and drowsiness
• Dry mouth
• Difficulty concentrating
• Blurred vision

As with any treatment, be sure to consult with your doctor if interested in taking any medicine for your menopause symptoms.

Clonidine

Clonidine is popular as a non-hormonal alternative to HRT for menopause symptoms, usually taken orally two or three times a day. Once treatment has begun, it can take several weeks until improvements begin to show.

Once popular, clonidine has since fallen out of favour as a HRT alternative. This is as a result of the negligible impact the drug has on symptoms, as well as the uncomfortable side effects the drug is reported to cause. One meta-analysis including 10 trials found inconsistent results for the effectiveness of clonidine on hot flashes.

There is some evidence pointing towards the effectiveness of clonidine for menopause symptoms:

• Small-scale studies have shown that clonidine can help with the frequency, duration and intensity of hot flushes.
• In one randomised, double-blind trial, women taking clonidine noted an additional 20 percent reduction in hot flashes compared to the placebo group; in another, it was an additional 14 percent. However, both groups noted very troublesome side effects, including sleeping problems, itchiness, dry mouth and nausea.

Side effects of clonidine for menopause symptoms can include:

• Drowsiness
• Dry mouth
• Low mood
• Constipation
• Sleeping difficulties

If you think clonidine might be a suitable medication for your menopause symptoms, or you’re experiencing troublesome side effects, be sure to consult your doctor.

Bioidentical or ‘natural’ hormones

Bioidentical hormone therapy uses hormones identical to those produced by the body to replace those that decline during the menopause.

These bioidentical hormones are made from plant sources and are often touted as a ‘natural’ alternative to hormone replacement therapy, sold as preparations by ‘specialist pharmacies’ in the UK.

Many hormones used in regular HRT are made from natural sources; these have been through rigorous testing and are authorised by regulators. These bioidentical hormone treatments, on the other hand, do not follow a regulatory pathway of evaluation by the MHRA, nor has their effectiveness been properly evaluated in randomised clinical trials.

According to the British Menopause Society, many prescribers of bioidentical hormone therapy are often healthcare professionals who are not experts in menopause medicine. The hormone preparations used are often based on your saliva’s hormone levels, which can produce medicines that aren’t guaranteed to alleviate menopause symptoms.

There is a paucity of large-scale research into the effectiveness of these types of preparations for controlling menopause symptoms, but some trials have pointed to their benefits.

Evidence of the benefits of bioidentical hormones for menopause symptoms:

• In a study of 69 women, bioidentical hormone therapy improved quality of life by 52 percent and was ‘effective in reducing menopausal symptoms’ including sleep problems, fatigue, hot flushes, tension and loss of libido.
• According to a review, bioidentical hormones have ‘demonstrated effectiveness in addressing menopausal symptoms’.

Bioidentical hormones should not be confused with body-identical hormones, such as those used in HRT. Micronised progesterone is a body-identical type of progestogen used in HRT which has been authorised by regulators (like the MHRA in the UK).

Be sure to have a discussion with your doctor if you’re considering bioidentical hormone therapy for your menopause symptoms.

Alternatives to HRT: see what works for you

HRT can have a transformative effect on the menopause symptoms of many women, but not every woman is suitable for the treatment, or comfortable with taking it.

As well as being fabulous advice for people of any age, research demonstrates the impact that a good diet, mindful breathing and regular exercise can have in diminishing some of the most uncomfortable menopause symptoms.

There is also evidence that some types of antidepressant and alternative medicines can provide relief from menopause symptoms. Always make sure to consult your doctor if you’re thinking of starting a new treatment or medicine for your menopause symptoms.

At Inspired Health, we’re the official UK home for many leading health brands, including Cleanmarine and their leading MenoMin all-in-one supplement, specially formulated for menopausal women.

For more information and insight-led articles on the menopause, head over to The Menopause Blog.