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How to beat the HRT shortage ... with alternative remedies that could keep those hot flushes at bay

Daily Mail logo Daily Mail 12/08/2019 Fiona Macrae for the Daily Mail

 Thousands of women who rely on hormone replacement therapy (HRT) to cope with the menopause are finding it hard to get their prescription filled in UK pharmacies, as the Mail first reported on Saturday.

There is a nationwide shortage of HRT, the most common treatment for menopausal symptoms including night sweats, hot flushes and mood swings.

Used by about 200,000 women in the UK, HRT can be given as patches, pills or gels, providing the female hormones the body stops producing at the end of a woman’s fertile life.

So if you can’t get hold of HRT, what are the alternatives — and do they work? © Provided by Associated Newspapers Limited So if you can’t get hold of HRT, what are the alternatives — and do they work?

Boots and LloydsPharmacy are among those said to be experiencing the shortage, which started in December 2018 and has worsened in recent weeks.

The Department of Health and Social Care is aware of the supply issue, which it says has been caused by manufacturing delays. But Helen Stokes-Lampard, chair of the Royal College of General Practitioners, has said that the underlying reason remains unclear because it is commercially sensitive. ‘Nobody will be honest with the public and the NHS,’ she said. ‘It’s frustrating.’

LloydsPharmacy supplier AAH Pharmaceuticals has run out of 15 of the 24 HRT brands it usually stocks, while pharmaceutical retailer Alliance, which is owned by the same group as Boots, has run out of nine of 27 HRT products.

Used by about 200,000 women in the UK, HRT can be given as patches, pills or gels © Provided by Associated Newspapers Limited Used by about 200,000 women in the UK, HRT can be given as patches, pills or gels

Now, women are panic-buying, which adds to the problem. Sid Dajani, of the Royal Pharmaceutical Society, says women are coming to his pharmacy in Hampshire asking for a six-month supply of HRT, instead of their usual three months, having persuaded their doctors to write extra prescriptions.

So if you can’t get hold of HRT, what are the alternatives — and do they work? Here, we assess the options. Always ask a doctor before trying a new treatment.

Herbal Help 

Black Cohosh, sold as a powder, pill or capsule © Provided by Associated Newspapers Limited Black Cohosh, sold as a powder, pill or capsule

Black cohosh

What is it? Made from the root and rhizomes of a plant native to North America, it is sold as a powder, pill or capsule taken two to three times a day. Different preparations contain different strengths and doses may vary.

Is it effective? ‘Some studies show that black cohosh may ease menopausal symptoms including mood swings and hot flushes. However, other studies have found it has no significant benefit,’ says Dr Heather Currie, an obstetrician and former chair of the British Menopause Society. Side-effects can include headaches, tummy upset and dizziness.

Red clover

What is it? Native to Europe, red clover contains phytoestrogen, a plant hormone that acts in a similar way to oestrogen, and is taken as capsules or powder.

Is it effective? ‘Research shows it may have a beneficial effect on menopausal symptoms,’ says Dr Currie. A study published in the journal PLoS One in 2017 found that fermented red clover extract may help to reduce the severity of night sweats and hot flushes and prevent menopausal bone loss, which affects one woman in three over the age of 50.

However, the researchers were cautious about saying red clover works — it could be the fermentation process that makes the difference, they said, as it allows the body easily to access the oestrogen-like compounds in red clover. Side-effects may include a rash, muscle ache and nausea.

Evening primrose oil

What is it? This oil, from the seeds of the plant, is rich in gamma-linoleic acid, an essential fatty acid involved in the production of hormone-like substances called prostaglandins. Excess prostaglandins are thought to counter the hormonal changes associated with the menopause.

Is it effective? Results are mixed, but a study of 80 postmenopausal women published in the Journal of Education and Health Promotion in March 2018 found it did help to reduce hot flushes and improve quality of life.

‘Some women find it helps breast tenderness in particular,’ says Dr Currie. Side-effects are normally mild, but can include nausea, diarrhoea and indigestion.

food on a table: A bottle of evening primrose oil with fresh evening primrose flowers in the background © Provided by Associated Newspapers Limited A bottle of evening primrose oil with fresh evening primrose flowers in the background

St John’s wort

What is it? Synthesised from a European plant, this is used mainly to produce a remedy for mild to moderate depression, anxiety and sleep problems. It can also be used to treat mood changes due to the menopause, with the plant chemical hypericin said to act on messengers in the nervous system which regulate mood.

Is it effective? ‘Some studies suggest it might help ease low mood caused by the menopause, but there is a lack of robust evidence and also a lack of regulation around production,’ says Mike Bowen, a consultant gynaecologist in Harley Street.

It can also interact with other medication, including tamoxifen, used to treat some types of breast cancer, so always check with a doctor. Side-effects may include insomnia and vivid dreams.

a glass cup on a table: Freshly brewed tea with dried St. John's wort in a glass mug on a wooden table (stock) © Provided by Associated Newspapers Limited Freshly brewed tea with dried St. John's wort in a glass mug on a wooden table (stock)

Fennel cream

What is it? This is a preparation from an anise-flavoured plant used in cooking, which can help to ease vaginal dryness and vaginal atrophy (thinning, drying and inflammation of the vaginal walls due to less oestrogen) caused by the menopause. It is usually administered as a 5g dose once a day.

Is it effective? ‘It is a lubricant so it will help to ease dryness,’ says Sid Dajani.

One clinical study, published in the journal Maturitas in 2016, found it was effective in managing vaginal atrophy and had no side-effects. It may also help relieve sleeplessness and anxiety, according to a U.S. study.

Drug treatments

Gabapentin

What is it? Typically prescribed to treat epilepsy, it has also been used in lower doses as a non-hormonal way to reduce menopausal hot flushes. The usual dose is 300mg three times daily.

Is it effective? Studies show it can reduce hot flushes for at least 12 weeks. But side-effects may include drowsiness, lightheadedness and dizziness. This has to be prescribed by a doctor and is not used routinely.

Clonidine

What is it? Normally used for high blood pressure and to prevent migraines, it is a drug some GPs are now prescribing to treat hot flushes. It is usually taken in a 50mg to 75mg dose twice a day.

Is it effective? Sid Dajani says there is no hard evidence it has any effect. ‘If you have no benefits after two to four weeks, treatment should be stopped,’ he says. Side-effects may include feeling sick, drowsiness and a dry mouth.

a close up of a fan: The most commonly prescribed forms of the menopause drug treatment are out of stock in pharmacies across the country in a crisis that is getting ‘worse and worse’ (file image) © Provided by Associated Newspapers Limited The most commonly prescribed forms of the menopause drug treatment are out of stock in pharmacies across the country in a crisis that is getting ‘worse and worse’ (file image)

SSRIs

What are they? These are a class of drug known as selective serotonin reuptake inhibitors, which include Prozac (fluoxetine) and Cipramil (citalopram) and are usually used to treat depression. Women with menopausal hot flushes are usually prescribed low-dose 20mg tablets once a day.

are they effective? ‘Studies show SSRIs are effective at treating menopausal symptoms such as hot flushes and mood swings, but may take up to eight weeks to have any effect,’ says Mike Bowen. Side-effects may include drowsiness, weight gain and nausea.

SSRIs, as the Mail has highlighted, can also, more rarely, cause sexual dysfunction in women.

Lifestyle tweaks  

Relaxation techniques and dietary changes are effective ways to reduce anxiety associated with the menopause.

Acupuncture

What is it? The ‘needle therapy’ first used in China 2,000 years ago is still a popular alternative treatment. Fine needles are inserted at points around the body to ‘correct flows of energy’.

Is it effective? In a small 2011 study, researchers found menopausal women who had needle therapy for ten weeks had less severe hot flushes and mood swings than those who had dummy acupuncture with blunted needles. However, the jury is still out as to whether acupuncture can really make a difference.

Critics of the technique attribute any benefits to the placebo effect.

Are plant-based hormones the answer?

Bioidentical hormones are plant-based and promoted as a more natural, gentler form of HRT. Derived from plants such as Mexican yams, they have the same structure as the hormones made naturally in the body and, like conventional HRT, combat the menopause by raising levels of oestrogen.

They are available only privately, costing around £350 for a year’s supply, and preparations are custom-mixed for individual patients, based on the results of a blood or saliva test. They can be given as a lozenge, patch, cream or vaginal gel. Advocates say the fact they are chemically identical to human hormones means they are safer than conventional HRT and have fewer side-effects. However, doctors warn they are unregulated and so do not have to undergo the same level of testing.

The NHS does not recommend bioidentical hormones, saying it is unclear how safe or effective they are, and the British Menopause Society has warned they are prescribed by ‘clinicians who usually do not have any recognised menopause training’.

Meanwhile, critics query how natural these hormones really are, since they are processed in laboratories so they match human ones. Exempt from NHS supply chain pressures, which are affecting its stocks of HRT, bioidentical hormones are still available — but Dr Heather Currie, an obstetrician, advises against switching.

‘The HRT we prescribe has been fully tested and we know the doses of the hormones it contains — people don’t necessarily know what they are getting with [custom-mixed bioidentical] preparations,’ she says. 

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