Patient information: Postmenopausal hormone therapy alternatives

Richard J Santen, MD
Section Editors
Peter J Snyder, MD
William F Crowley, Jr, MD
Deputy Editor
Kathryn A Martin, MD

Last literature review version 18.2: May 2010 | This topic last updated: February 5, 2010

INTRODUCTION — During a woman's reproductive years, the body produces a variety of hormones, including estrogen. Estrogen is important for normal menstrual periods and fertility, and it promotes bone strength. Estrogen levels fall at the time of menopause, causing well-known symptoms such as hot flashes.

Postmenopausal hormone therapy is the term used to describe the two hormones, estrogen and progestin, that are the most effective treatments available to relieve bothersome symptoms of menopause. However, some women cannot or do not want to take hormone therapy. Alternatives to hormone therapy are available.

This article discusses alternatives to postmenopausal hormone therapy. A separate article discusses the risks, benefits, and options for hormone therapy. (See "Patient information: Postmenopausal hormone therapy".)

PREVENTING AND TREATING OSTEOPOROSIS — When estrogen levels fall, bone density and bone strength begin to decline. Over time, this can lead to osteoporosis and an increased risk of fractures. A test to monitor bone density can detect early bone loss and is recommended for most women beginning at age 65. Younger women and men might also benefit from bone density testing, as described in a separate article. (See "Patient information: Bone density testing".)

Several treatments can help keep bones strong and prevent fractures caused by osteoporosis. The most effective treatments include a combination of a healthy diet, lifestyle, and medicine. More detailed information about treatment of osteoporosis is available separately. (See "Patient information: Osteoporosis prevention and treatment".)

Calcium — Calcium is an essential component of bones; calcium from foods we eat can help strengthen bones. However, calcium alone cannot always prevent osteoporosis.

All postmenopausal women need 1500 mg of calcium each day. Most women will need to eat a well-balanced diet and take a daily supplement that contains 1000 mg of calcium, usually in the form of calcium carbonatecalcium citrate, or an equivalent. A list of calcium-rich foods and guidelines for choosing calcium supplements is available in the table (table 1). (See "Patient information: Calcium and vitamin D for bone health".)

Vitamin D — Vitamin D helps the body absorb and incorporate calcium into bone. Many adults have low levels of vitamin D, including about 50 percent of postmenopausal women taking medicine for osteoporosis. All postmenopausal women should get at least 800 IU of vitamin D each day in foods or with a supplement. Some calcium supplements and multivitamins include vitamin D, so it is important to read the label to determine how much you are getting. (See "Patient information: Vitamin D deficiency".)

Exercise — Bones stay stronger when they are used in day-to-day activities. Not being active increases the risk of losing bone strength after menopause. At least 30 minutes of weight-bearing exercise three times a week can reduce this risk. Weight-bearing exercise includes activities such as walking, aerobics, or tennis, but do not include bicycling or swimming.

Medicines — Several medicines can help prevent or even reverse osteoporosis by boosting bone density

(table 2). These medicines can even help women who have already suffered fractures. You should continue to take calcium, eat a healthy diet, and exercise to strengthen your bones as you take these medicines. Treatment of osteoporosis is described in detail in a separate topic review. (See "Patient information: Osteoporosis prevention and treatment".)

PREVENTING CORONARY HEART DISEASE — The decrease in estrogen levels after menopause increases the risk of developing and dying from a heart attack. Treatments are available to reduce some of the risk factors associated with heart attack, such as high cholesterol levels.

Stop smoking — Quitting smoking is probably the most important change you can make to decrease your risk of developing heart disease. Ask your doctor or nurse about methods for successfully quitting. (See "Patient information: Quitting smoking".)

Eat a healthy diet — A heart-healthy diet may be recommended first to get your cholesterol levels under control. If this approach does not lower your cholesterol levels enough, or if you have a high risk for heart diease, your doctor or nurse may recommend a cholesterol-lowering medication. (See "Patient information: Diet and health".)

Manage cholesterol levels — In postmenopausal women with high cholesterol levels or a high risk of coronary heart disease, medicines that lower levels of cholesterol are often recommended. (See "Patient information: High cholesterol and lipids (hyperlipidemia)".)

CONTROLLING HOT FLASHES — Non-hormone treatments for hot flashes are effective in many women. None work nearly as well as estrogen. Not all women need treatment for hot flashes since they typically go away after about 4 to 5 years, even without treatment. Non-hormone treatments include:

Antidepressants — Antidepressant medications are recommended as a first line treatment for hot flashes in women who cannot take estrogen.

  • Venlafaxine (Effexor®), paroxetine (Paxil®), and desvenlafaxine (Pristiq®) were developed to treat depression, but studies show that they are an effective treatment for hot flashes. You should not take paroxetine (Paxil®) if you have breast cancer and are taking tamoxifen. The concern is that paroxetine can interfere with tamoxifen and make it less effective.

  • Fluoxetine (Prozac®) and citalopram (Celexa®) are also effective, but might not work as well as venlafaxine, paroxetine, or desvenlafaxine.

  • Sertraline (Zoloft®) is not helpful for treating hot flashes.

Other antidepressant side effects and interactions are discussed in detail in a separate article. (See "Patient information: Depression treatment options for adults".)

Gabapentin — Gabapentin (Neurontin®) is a drug that is primarily used to treat seizures. Although it has not been as well studied as antidepressants, it does relieve hot flashes in some women. To minimize side effects and decrease night sweats, your doctor might recommend taking gabapentin at bedtime. This approach would not reduce daytime symptoms, although many women are less bothered by hot flashes in the daytime than nighttime.

Progesterone — The injectable progestin birth control hormone, medroxyprogesterone acetate (Depo-Provera®) may help to reduce hot flashes. Depo-Provera® may be used long-term, although it can cause side effects such as weight gain and loss of bone density.

Plant-derived estrogens (phytoestrogens) — Plant-derived estrogens have been marketed as a "natural" or "safer" alternative to hormones for women with menopausal symptoms. Phytoestrogens are found in many foods, including soybeans, chickpeas, lentils, flaxseed, lentils, grains, fruits, vegetables, and red clover.

There is no evidence that phytoestrogens help to reduce hot flashes or night sweats. In addition, phytoestrogens might increase the risk of breast cancer risk because they act like estrogen in some tissues of the body. Women who have a history of breast cancer should avoid phytoestrogens.

Herbal treatments — A number of herbal treatments have been promoted as a "natural" remedy for hot flashes. However, no herbal treatment or combination has been found to relieve menopausal symptoms. In addition, there are safety concerns about some herbs, including black cohosh, which might stimulate breast tissue (similar to estrogen). Herbal treatments are not recommended for hot flashes or other menopausal symptoms.

TREATING VAGINAL DRYNESS — Treatment options for vaginal dryness are discussed in a separate article. (See"Patient information: Vaginal dryness".)

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed every four months on our Web site (

Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information

Patient information: Postmenopausal hormone therapy
Patient information: Bone density testing
Patient information: Osteoporosis prevention and treatment
Patient information: Calcium and vitamin D for bone health
Patient information: Vitamin D deficiency
Patient information: Quitting smoking
Patient information: Diet and health
Patient information: High cholesterol and lipids (hyperlipidemia)
Patient information: Depression treatment options for adults
Patient information: Vaginal dryness

Professional level information

Androgen production and therapy in women
Clinical manifestations and diagnosis of vaginal atrophy
Continuous postmenopausal hormone therapy
Estrogen and cognitive function
Menopausal hot flashes
Postmenopausal hormone therapy and cardiovascular risk
Postmenopausal hormone therapy and the risk of breast cancer
Postmenopausal hormone therapy in the prevention and treatment of osteoporosis
Postmenopausal hormone therapy: Benefits and risks
Preparations for postmenopausal hormone therapy
Treatment of menopausal symptoms with hormone therapy
Treatment of vaginal atrophy

The following organizations also provide reliable health information.

  • The Hormone Foundation

      (, available in English and Spanish)

  • National Center for Complementary and Alternative Medicine



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1.    Nedrow, A, Miller, J, Walker, M, et al. Complementary and alternative therapies for the management of menopause-related symptoms: a systematic evidence review. Arch Intern Med 2006; 166:1453.

2.    Pinkerton, JV, Santen, R. Alternatives to the use of estrogen in postmenopausal women. Endocr Rev 1999; 20:308.

3.    Treatment of menopause-associated vasomotor symptoms: position statement of The North American Menopause Society. Menopause 2004; 11:11.

Alternatives to HRT​

Peter T. Simonson, MD, PLLC

Obstetrics and Gynecology