Eighty per cent of women will experience menopausal symptoms such as hot flushes, mood changes and insomnia. Hormone replacement therapy has been highly effective in alleviating these symptoms by normalising the hormone deficiency around the time of the menopause. For years it has been considered the gold standard, but many women have felt uneasy with HRT, perceiving it as "unnatural". Now, new evidence from several large clinical trials has sharply increased this feeling of unease, and even the experts have started to have second thoughts about HRT.
The facts can be confusing. First, no other treatment is more effective in reducing menopausal symptoms such as hot flushes. HRT also reduces the risk of osteoporosis and bone fractures long after the menopause. On the other hand, HRT has been found to increase the risk of stroke, myocardial infarction, venous thromboembolism and breast cancer. The risk increments are relatively small. If, for instance, 1,000 women were treated with HRT for five years, this would cause breast cancer in two to six of them.
In the light of this mixed evidence, the best course of action is to seek advice that takes into account a woman's personal preferences and risks. Only then can a balanced decision be reached as to whether or not the benefits of HRT outweigh its newly recognised risks.
Even so, many women are desperate for alternatives. Herbal medicines are now heavily promoted as risk-free solutions to the HRT conundrum. Research into herbal treatments has so far, however, been scarce: the funds available are nowhere near as generous as for HRT. While the majority of British women are tempted to try herbal remedies, neither the government nor medical charities invest more than 1% of their medical research budgets in the study of this field. In my view, there are few areas of complementary medicine that require research more urgently. Nevertheless, the little research that has been done offers some encouraging evidence.
Several trials have suggested that black cohosh extracts reliably alleviate menopausal symptoms and prevent the long-term consequences of the menopause. Some say that the effects of this remedy are probably not unlike oestrogen. Unfortunately, this could mean that its risks are also not dissimilar, but the lack of reliable evidence means that we cannot be sure.
Perhaps the best-researched herbal remedy for menopausal symptoms is red clover. No less than seven clinical trials are now available. The totality of this evidence shows indisputably that red clover is effective in reducing symptoms, in particular hot flushes. There is also evidence to suggest that it might prevent osteoporosis, and one study reports that it may protect some women from heart disease. Unfortunately, we don't yet know whether red clover carries any of the risks of HRT. And its benefits, although proven, are smaller than those provided by HRT.
In the UK, herbal remedies are not yet regulated as stringently as conventional drugs. This means that the quality of the products can differ vastly. Some of the remedies, particularly those at the cheaper end of the spectrum, may be underdosed, for instance. My advice is to buy from a reputable source. Ask a knowledgeable healthcare professional, such as a medical herbalist, for advice if you are in doubt.
Does complementary medicine offer anything else for menopausal women? Relaxation techniques can make hot flushes more bearable; soy contains plant-based oestrogen and can combat oestrogen deficiency, so including soy in your diet may not be a bad idea. Regular exercise beats depression and, on top of this, helps in preventing osteoporosis. The trouble with exercise is, of course, that we all know how good it is but most of us don't have the time, energy or will do to something about it.
Many other therapies are regularly recommended. Anyone who searches on the internet will find dozens, if not hundreds, of "alternatives" to HRT. However, the evidence is either totally absent or not strong enough for any positive recommendations.
In recent months, both patients and experts have had second thoughts about HRT. Because so many women experience menopausal problems, we should now look seriously and systematically for alternative options. Complementary medicine might well offer some solutions. All we need is proper research - and, of course, the funds to finance it.
· Edzard Ernst is professor of complementary medicine at the Peninsula medical school at the Universities of Exeter and Plymouth.