Alternatives to HRT

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Alternatives to HRT

O e s t r o g e n

• Dr Beverley Lawton
• Womens Health Research Centre
• Wellington Menopause Clinic

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Useful references

• www.otago.ac.nz/whrc
• www.menopause.org.au
• www.nlm.nih.gov/medlineplus/druginfo

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Overview

• Why treat?
• CAMS
• Prescription medications

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The Dilemmawhy treat at all?!

• Common reason for seeking medical
  advice 1
• Significantly affect QoL
  for 25 of women
• For 10-20 of women these symptoms persist for
  more than 10 years 2

1. Haimov-Kochman et al (2005) Acta Obstet
Gynecol Scand 84 972-979 2. Position Statement,
Menopause.11(1)11-33, 2004
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Sleep Disturbance

• Increases the risk of accidents
• May decrease work place performance
• Affects family life 1

• Associated with increased risk of illness such
  as obesity, diabetes, hypertension and diabetes
  2, 3
• 1. Rosenthal M. Menopause200310(1)4-5.
• 2. Ayas NT,et al. Arch Intern Med
  2003163(2)205-209.
• 3. Gottlieb DJ et al Arch Intern Med
  2005165(8)863-867.

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Natural is good marketing
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Natural
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All therapeutic agents have

• Risks
• Benefits
• Side-effects
• Interactions
• Dilemma in not treating
• Opportunity Costs
• Placebo effect

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Ginseng example

• Benefits. Benefits in mental performance have
  been seen both in healthy young people and in
  older ill patients.
• Risks skin rash or spots, itching, diarrhoea,
  sore throat, loss of appetite, excitability,
  anxiety, depression, or insomnia.
• Side effects (Less common) headache, fever,
  dizziness/vertigo, blood pressure abnormalities
  (increases or decreases), chest pain, difficult
  menstruation, heart palpitations, rapid heart
  rate, leg swelling, nausea/vomiting, or manic
  episodes in people with bipolar disorder.

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Ginseng example

• Interactions
• may reduce the anticoagulant (blood thinning)
  effects of warfarin
• Headache, tremors, mania, or insomnia may occur
  if ginseng is combined with prescription
  anti-depressant drugs called monoamine oxidase
  inhibitors (MAOIs ), aloe vera , bilberry, bitter
  melon, burdock, fenugreek, fish oil, gymnema,
  horse chestnut seed extract (HCSE), marshmallow,
  maitake mushroom, milk thistle, rosemary,
  stinging nettle, and white horehound.
• http//www.nlm.nih.gov/medlineplus/druginfo/natura
  l/patient-ginseng.html

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Complementary and Alternative Medications (CAMS)
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CAMS

• Increasingly used
• Surveys in USA estimate approximately 40 of
  adults have used CAMS in the last year
• The risks and benefits of many of these drugs are
  unknown
• Increasing focus for research as we search for
  safe alternatives to HRT

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What does NOT work ?

• Dong quai, evening primrose oil, ginseng,
  acupuncture, magnetic therapy, evening primrose
  oil, melatonin,- no affect when compared to
  placebo1
• Wild yam cream1 Vitamin E 2
• Exercise - recent evidence suggests exercise may
  increase vasomotor symptoms but improves QoL3
• Kava improves anxiety but not flushes
• 1. Position Statement, Menopause.11(1)11-33,
  2004
• 2. Fitzpatrick L Med Clin N Am 87 (2003)
• 3. Aiello J Menopause 11(4) 2004

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No proven benefit

• Chasteberry, fish oil
• Flaxseed oil, Ginkgo
• Gotu kola, liquorice root, omega-3 fatty acids
• Passion flowers, sage, valerian root 1
• 1. Fugate SA, Pharmacother 2004 38 1482-99

Fish oil tablets
Passion flower
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Phyto-oestrogens

• Results from RCTs to date have been conflicting.
• GI side-effects, Soy is goitrogenic 1
• Possible negative effects on breast cell
  proliferation 2

• Not to be recommended in breast cancer patients
• 1. Fugate S Ann Pharmacother 2004381482-99
• 2. http//nccam.nih.gov/news/pastmeetings/blackcoh
  osh_mtngsumm.pdf

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Black Cohosh (Cimicifuga racemosa)

• Variable results concerning efficacy in treating
  menopause symptoms 1
• But recent trials report no benefit above
  placebo2
• Safety concerns re. reports of fulminant
  hepatitis lead to NIH workshop in 2005 3
• 1. Position Statement, Menopause.11(1)11-33,
  2004
• 2. BMJ 2006 update search black cohosh
• 3. http//nccam.nih.gov/news/pastmeetings/blackcoh
  osh_mtngsumm.pdf

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Black Cohosh

• Experimental breast data suggests BC increases
  the toxicity of some cancer drugs.
• Animal models - increased spread cancer in mouse
  mammary cancer model

Black cohosh flower
http//nccam.nih.gov/news/pastmeetings/blackcohosh
_mtngsumm.pdf
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Prescription Medicines

• Antidepressants Venlafaxine, Paroxetine,
  Fluoxetine
• Shown to have variable affect on vasomotor
  symptoms. Generally fast acting 1
• May be useful in breast cancer and/or presence of
  depression
• Nine month RCT - citaloprim and fluoxetine showed
  no effect on flushes compared to Placebo 1

1. Suvanto-Luukkonen Menopause.12(1)18-26,2005
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Antidepressants

• Caution as regards side-effects
• Small numbers and short
  duration of trials to date
• Venlafaxine has been
  associated with hepatitis 1
• 1. Phillips B Ann. (2006) Pharmacoth 40(2)
  323-327

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Clonidine

• May be helpful
• Side-effects limit use
• Drowsiness
• Tiredness
• Constipation
• Dry mouth
• Headache
• Dizziness

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Gabapentin

• An RCT of 59 women showed reduction of hot
  flushes by 45 compared to 29 placebo 1 another
  as effective as oestrogen 3
• Adverse effects - somnolence, headache,
  dizziness, ataxia, fatigue, disorientation and
  nystagmus (1 in 4)
• Safe and effective for short term use 2
• 1. Guttuso T,Obstet,Gynecol 2003101337-345
• 2. Fugate S Ann Pharmacother 2004381482-99
• 3. Siresha Y, Obstet,Gynecol 2006108, NO1

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Bio-identicals, NHRTwww.otago.ac.nz/whrc

• Compounded therapies
• Often contain mixtures of powerful hormones
• Efficacy, safety and pharmaco-kinetics unknown1
• Must be considered experimental therapies
• Position Statement, Menopause.11(1)11-33, 2004

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Progesterone Cream

• Conflicting efficacy data
• Variable uptake
• No bone protection
• Limited safety data for the uterus
• Long term safety data needed
• Davis SR et al, J Endocrinol (2005) 185, 207-222
• www.otago.ac.nz/whrc

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Dont forget what we sit on!

• Vaginal dryness is common
• Intercourse can be painful if not impossible
• Vaginal lubricants can help
• In most cases topical or oral oestrogen will be
  needed

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Summary

• There is a significant need for appropriate
  treatments for menopause symptoms
• There are alternative options of varying efficacy
  and safety

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Thank youwww.otago.ac.nz/whrc
Womens Health Research Centre Research making
a difference to women