Alternatives to HRT

1. Benha University Hospital, Egypt
2005ABOUBAKR ELNASHAR

2. 36% of adults in the U.S. had used
some form of alternative therapy
within the previous 12 months
46% of women used CAM for
menopausal symptoms.
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3. Why Alternatives to HRT are
requested?
1. Contraindication to HRT
2. Belief that HRT interfere with nature
3. Fear of long term effects of HRT
4. Fear of adverse effects.
5. Lack of information about HRT
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4. 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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5. ABOUBAKR ELNASHAR

6. Alternatives to HRT
1. Lifestyle Changes
2. Dietary changes & supplements
3. Complementary therapies
4. Drugs
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7. Avoid
•trigger factors for vasomotor symptoms.
•risk factors for osteoporosis.
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8. 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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9. 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.
Alcohol:
higher risk for breast cancer with even moderate
intake (Stampfer et al, 2005)
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10. Plan for to quit smoking (Malat,2005):
Pick a quit date,
visualize yourself as a nonsmoker;
seek out support from friends and family;
recognize the triggers and find substitutes; and
consider using medication, such as the nicotine patch
and bupropion.
The most successful method of overcoming the
smoking habit is a combination of both behavior-
modification therapy and prescription drug treatment.
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11. Excercise:
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
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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12. Type:
Regular
Weight bearing.
The safest excercise is walking
30 minute 4-5 times /w.
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13. A balanced diet should comprise whole grains,
fruits, vegetables, minerals and vitamins, with
a minimal amount of saturated fats.
Calcium with vitamin D supplementation is
recommended
I. Multivitamins.
II. Minerals.
III. Natural hormones.
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14. 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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15. 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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16. 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 2:1.
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17. •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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18. 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 < 5 mg daily in western diet.
Derived from
plants
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19. 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
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20. Available in:
tablet (Klimadynon=cimicifugae)
food supplements in bread,
snack bars,
health drinks.
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21. 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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22. 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 RCT. So, it is not possible to draw absolute
conclusions. Evidence to date on whether it is
protective is inconclusive
(Weaver & Cheong, 2005)
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23. 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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24. 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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25. 1. Herbalism.
2. Acupuncture.
3. Stress reduction.
4. Homoeopathy.
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26. •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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27. 1. Herbalism:
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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28. A.Black cohosh (Cimmicifugae racemosae)
Binds to estrogen receptors & suppresses
luteinizing hormone
(Viereck et al, 2005)
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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29. B. St John s Wort (Hypericum)
Dose: 900 ug daily.
Effective in reducing flushes, low mood,
insomnia mild-to-moderate depression
(Grube et al, 1999).
Drug interactions with theophylline, digoxin,
cyclosporin, combined oral contraceptive
pills.
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30. Valerian:
contains a gamma aminobutyric acid (GABA)
used as a tranquilizer and soporific. Chamomile tea also
contains a GABA-like compound and is preferred as a sleep
aid.
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:
not effective in a placebo RCT
(Chenoy et al, 1994)
Chinese herbs:
not effective in placebo RCT
(Davis et al, 2001)
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31. 2. Acupuncture:
Significant reduction in vasomotor symptoms
& the benefits continued for 3 weeks
(Wyong et al, 1995; Tukmachi, 2000).
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32. 3. Stress reduction:
•Encouraging women
to reassess their priorities in life,
to reduce unnecessary stress that in turn may
alleviate some symptoms.
•Relaxation exercises were found to decrease
the number of hot flashes.
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33. 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.
Some women use alternative measures to
reduce stress, including yoga, massage,
biofeedback, acupuncture, and hypnosis.
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34. 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 skeptics, although as an alternative
treatment, it is safe.
•RCT are needed to clarify its value in the
menopause.
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35. 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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36. I. For prevention & treatment of osteoporosis
II. For treatment of vasomotor symptoms
III. For symptomatic treatment of atrophic
vaginitis
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37. Many are effective but only for single problem.
I. For prevention & treatment of osteoporosis
1. Bisphosphonates
2. Raloxifene
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38. 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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39. 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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40. 2. Night sedation:
For insomnia & mood swings
3. Veralipide (Agreal):
100 mg daily for 20 days, repeated after 7
days. It is neuroliptic
4.Gabapentin (Neurontin):
used to treat seizures, has achieved
reductions in the number or severity of
vasomotor symptoms within 1 week
(Guttuso, 2000).
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41. 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. Propranolol:
No data to support its use
(Brockie, 2002)
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42. III. For symptomatic treatment of atrophic
vaginitis
1. Simple vaginal lubricants: Astroglide,
Lubrin, replens
2. Long acting bioadhesive vaginal
moisturiser: Gynemoistrin
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.ABOUBAKR ELNASHAR

43. 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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44. ABOUBAKR ELNASHAR

45. 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
ABOUBAKR ELNASHAR

46. 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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47. ABOUBAKR ELNASHAR