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Prescribable Alternatives to HRT


Most prescribable alternative therapies have been evaluated for their impact on vaso-motor symptoms. Some of them also have an impact on mood and well-being. The class effect of the drug is important in selecting what is likely to be the best alternative for your patient. Menopause treatments also tend to have a high placebo response often as great as 50% which may enhance quoted “baseline effectiveness”.

  Added benefit  Dose Added Benefit Adverse Effect
Gabapentin 50% Gamma amino-butyric acid analogue used to treat epilepsy, neurogenic pain and migraine; reduces hot flushes at a dose of 900mg per day

Improved quality of sleep
Reduced pain

Dry mouth dizziness and drowsiness with a very specific dose related component
Patients will find their own level
Weight gain

Pregabalin 50% 50-300mg in divided doses 

Improved quality of life 

Similar to Gabapentin but less marked and therefore better tolerated
More expensive
Clonidine no information 
25-50 mcg bd up to a maximum of 75 micrograms bd or 50mcg tds May complement other antihypertensive drugs
Only licensed option
Interaction with anti-hypertensive drugs and not suitable for patients with baseline low blood pressure
Must be reduced gradually otherwise causes rebound hypertension
Dose related side-effects include sleep disturbance in at least 50% of patients, dry mouth nausea and fatigue.
SSRI 20-50%   Class effect of SSRIs are of antidepressant benefit and improved quality of life. Class effect of SSRIs include initial side effects such as nausea, dizziness, shortterm aggravation of base-line anxiety and mood, so encourage your patient to persevere and if necessary take on alternative days, even ½ tablet
Class effect of all SSRIs is sexual dysfunction
No one SSRI is better than any other in this respect and there is great individual variation in response.
Paroxetine 50-60% Dosage 10-20mg –  Paroxetine has best evidence for vaso-motor control and has maximal benefit achieved at 10mg. Class effect of SSRIs are of antidepressant benefit and improved quality of life. Interacts with enzyme cytochrome P450 (CYN10) thereby rendering Tamoxifen less effective.
Fluoxetine 10-20% 20mg  Class effect of SSRIs are of antidepressant benefit and improved quality of life. Like Paroxetine should be avoided in patients taking Tamoxifen.
Citalopram (escitalopram) 40-50%. 20mg  Class effect of SSRIs are of antidepressant benefit and improved quality of life. Much less effect on enzyme cytochrome P450 so can be used in patients on Tamoxifen.

no information available

25-50mg  Sertraline is the best anti-anxiety SSRI The least well tolerated with an increase in anxiety at the outset.
Interacts with cytochrome P450, so avoid in patients on Tamoxifen
Venlafaxine 20-66% 37.5mg – 150mg sustained release preparations recommended Improved quality of life Antidepressant effect > Often poorly tolerated at outset with dizziness and other associated SSRI side effects including sexual dysfunction, slow titration may be the answer > NO interaction with cytochrome P450 so may be safest choice for patients on Tamoxifen.


 British Menopause Society

Reviewed By: Ask Shilpa Author

fluoxetine paroxetine venlafaxine Sertraline Citalopram Escitalopram Gabapentin Pregabalin Clonidine Tamoxifen

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