Women who are going through the menopause transition will often have hot flushes and night sweats. They’ll be looking for advice on treatments that can help to relieve their symptoms, as these can severely affect their daily life. The National Institute for Health and Care Excellence (NICE) published guidelines in 2015 and suggests hormone replacement therapy (HRT) as having the best research to help with symptom control.

This article was included in issue 96 (spring 2023) of The Menopause Exchange newsletter.

Research also shows that cognitive behavioural therapy (CBT) or talking therapies can help. Women who don’t want to use HRT could consider CBT with support from a psychologist.

Some menopausal women don’t want to, or can’t, take HRT and feel that CBT doesn’t help enough. In these cases, NICE 2015 guidelines suggest some prescribed non-hormonal treatments instead. These treatments include medicines that are licensed as anti-depressants or are used for blood pressure control, and medicines that are licensed for neuropathic pain or epilepsy but can help menopausal symptoms as well. New research has also looked at a medicine called oxybutynin, which is usually prescribed for overactive bladder symptoms or incontinence.

Clonidine

This medicine is used at higher doses to help with blood pressure control and can be used at lower doses for menopausal symptoms. It’s taken as tablets two or three times a day. Clonidine shouldn’t be used if you already have low blood pressure. If you are on high blood pressure medicines, your GP will monitor your blood pressure if they prescribe clonidine as well. In cases where clonidine hasn’t been effective and you decide to stop taking it, you need to be weaned off slowly so you don’t get rebound low blood pressure. Research suggests that clonidine only has a very small effect on menopausal symptoms. Side effects include a dry mouth, drowsiness or difficulty with sleeping, depression and constipation.

Antidepressants

These antidepressants are either Selective Serotonin Reuptake inhibitors (SSRIs) or Serotonin-Noradrenaline Reuptake Inhibitors (SNRIs). Paroxetine is an SSRI that’s licensed in the USA for menopausal symptom control in women with breast cancer. There are other anti-depressants in the SSRI group, but paroxetine and these other SSRIs are not licensed in the UK for menopausal symptoms. Your GP will help you decide which one to use and monitor your symptoms.

In women with breast cancer who are also taking a medicine called tamoxifen, SSRIs would generally only be used if other options don’t help to control their menopausal symptoms. Some research suggests that some SSRIs may block tamoxifen from protecting women with breast cancer from getting breast cancer again. In these cases, venlafaxine (an SNRI) may be prescribed instead.

Side effects with both anti-depressant groups can include feeling agitated, shaky or anxious, feeling sick or dizziness, and reduced sex drive. These will improve with time, but you should see your GP if they don’t. Other SSRIs assessed in short-term trials for menopause symptom control include fluoxetine and citalopram. Research with citalopram used by patients in Denmark suggests that this SSRI could be used alongside tamoxifen without any adverse effect on breast cancer recurrence risk, but longer clinical trials are needed.

Gabapentin and pregabalin

These two medicines are licensed for patients with epilepsy or neuropathic pain, but some research shows that gabapentin could be considered for menopause symptom control. In women with breast cancer and menopausal hot flushes, the dose of prescribed gabapentin is 300mg three times a day, starting with a lower dose that’s increased gradually. With drowsiness as a side effect, the full dose could be taken at night. Prescribed doses need to be balanced to help with symptom control.

Pregabalin is also licensed for people who are struggling with generalised anxiety disorder. There is more research testing gabapentin for menopause symptom control compared with pregabalin. Both gabapentin and pregabalin are classified as Class C-controlled substances as there have been reports of abuse and dependence among people taking them. Alcohol intake isn’t advised for people taking gabapentin or pregabalin due to an effect on breathing and the central nervous system.

Oxybutynin

This is a common treatment prescribed to help women struggling with urinary incontinence. There is ongoing research to see if it can also be used to help with menopausal symptoms. If you’re on other medicines, it’s important to check with your GP or pharmacist whether these may work in the same way as oxybutynin, as you may have an increase in side effects. For incontinence, pelvic floor exercises can help, and in severe cases of urine leakage, using incontinence pads can make it easier for women to get through the day.

Other non-hormonal help

All medicines come with some side effects, but these can be managed and warrant a discussion with your GP or pharmacist. It’s important to remember that lifestyle interventions can also help menopausal symptoms. These should be part of your holistic management plan and include regular exercise, stopping smoking, a healthy balanced diet, staying cool at night, and cutting down on caffeine, alcohol and spicy foods. Reducing stress levels with plenty of rest, a good work-life balance, and activities such as yoga and tai chi can help with relaxation. In cases of vaginal dryness due to the menopause, vaginal moisturisers or lubricants are available.

About the author

Dr Nuttan Tanna is a pharmacist consultant in women’s health. She runs weekly menopause and osteoporosis medication management clinics at Northwick Park Hospital, in Harrow, Middlesex

Created Spring 2023
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