Reviewed October 2019

I can’t take HRT, what are my options?

hrt alternatvies

When women approach menopause their levels of oestrogen and progesterone fall. This sudden fluctuation in hormone levels can cause the menopausal symptoms that many women will know well: hot flushes, night sweats, palpitations, and mood swings. A low level of oestrogen also causes bone breakdown and results in less bone-making cells to make new bone, so can, in turn, cause osteoporosis. Low oestrogen levels also mean less secretion from mucous cells in the vagina, leading to vaginal dryness.

Hormone replacement therapy, commonly know as HRT, is a treatment commonly used to lessen or eradicate these symptoms. It consists of either being given oestrogen (for women who have had a hysterectomy), or oestrogen with progesterone (for women who have naturally occurring menopause). HRT is available as tablets, skin patches, gels, vaginal creams, pessaries, or rings.

However, unfortunately HRT is not suitable for all women. Those who have a history of breast cancer, ovarian cancer, or womb cancer should not take it,1 because oestrogen treatment can make cancer develop more quickly.2 Women with a history of blood clots (deep vein thrombosis or pulmonary embolism) should also avoid HRT,3 as oestrogen makes the blood more likely to clot, therefore heightening the risk.

In women with high blood pressure, HRT can cause it to become even higher. However, this does not mean that HRT cannot be given to women with high blood pressure, but rather it is advised that blood pressure is controlled before starting HRT.4

In women with liver disease, it may not be advisable to start HRT5 because the liver is responsible for the breakdown of oestrogen, so if the liver fails to function normally this means the levels of oestrogen in the body may be too high.

It is still possible to get pregnant while taking HRT, so it is important to use appropriate contraception until two years after the last period for women under 50 years of age, and for at least one year after the last period for women over 50. During pregnancy, the levels of oestrogen in the body are high, so it would not be advisable to take HRT.

As with any medication, someone may choose not to take it because of the potential side effects and risks. With HRT, side effects, due to peaks and troughs in levels of hormones, may include breast tenderness, headaches, nausea, and vaginal bleeding. Some types of HRT have been associated with an increase in the risk of blood clots and an increase in the risk of breast cancer.6 Because of this, some people will decide that the benefits of HRT are not worth the very small risks.

However, there are some alternatives to HRT if you are looking to relieve your menopause symptoms and are unable to take HRT.

Oestrogen creams and lubricants

If vaginal dryness is the main troublesome symptom you are having, then the use of oestrogen creams and lubricants (even without oestrogen content) may help. Oestrogen will increase vaginal mucous gland secretions, thus solving any problems you are having with dryness. However, local treatments like this will not relieve other symptoms of menopause such as palpitations or hot flushes.


Tibolone is a synthetic hormone that mimics the actions of oestrogen and progesterone, with some testosterone effects. It can prevent osteoporosis,7 and relieve vaginal dryness and hot flushes, and has the additional benefits of enhancing mood and libido.8 It is useful for women who have endometriosis (womb tissue growing in other areas of the abdomen) and fibroids (soft tissue growths in the womb) as it does not appear to worsen these conditions.9

However, on the whole it may not be as effective as HRT,10 and it is only suitable for women who had their last period over a year ago. This is because it mimics progesterone, and so if it is taken by women who are still having periods it may cause irregular bleeding, as progesterone causes the womb lining to shed. Any irregular bleeding while taking tibolone will need investigation because it is difficult to know whether there are any other underlying causes such as cancerous changes to the womb lining.


As well as symptoms of anxiety and depression, some antidepressants can also help with hot flushes and night sweats. This is because these symptoms are produced by nerves that are part of the sympathetic nervous system. Antidepressants inhibit these nerves, and so these symptoms may be relieved. Unfortunately, however, antidepressants can have their own unpleasant side effects such as agitation, dry mouth, and dizziness. Antidepressants will not help with other menopausal symptoms such as osteoporosis.


Clonidine is a non-hormonal medication that can help with hot flushes and night sweats. It works by causing certain blood vessels to dilate which reduces blood pressure, thus lessening these symptoms. However, it is only effective in some women, and is not very strong. Again, it has no effect on other symptoms of menopause such as osteoporosis.

Bioidentical hormones

Bioidentical hormones are hormones that are identical to oestrogen and progesterone on a molecular level. Although there are claims that these help menopausal symptoms such as hot flushes, they are not recommended because there is no scientific evidence supporting any of these claims,11 and it is unclear how safe or effective they are.

Black cohosh and St John’s Wort

Both black cohosh (Actaea racemosa or Cimicifuga racemosa) and St John’s Wort are herbs that may be bought from health food shops. It is claimed that they can relieve symptoms of low mood, hot flushes, and night sweats, but the mechanism of how this happens is unclear. There has been some research into the use of these herbal remedies for menopausal symptoms, but the results are inconclusive and the herbs may or may not help.12,13 Generally, both are thought to be safe to take, but black cohosh has been reported to cause liver damage in some individuals.14

If my symptoms are mild will lifestyle changes be enough?

If your menopause symptoms are mild, there may be no need to use any medications at all to relieve them. Simple lifestyle measure may be helpful, including regular exercise, eating healthily, cutting down on coffee, spicy food, and alcohol, and stopping smoking.

Exercise helps build bone and muscle strength, thus helping to prevent osteoporosis, and the endorphins released during exercise will improve mood. There is no special diet that can help prevent menopause symptoms, but eating irregularly can make certain symptoms, such as tiredness, worse due to depleted glucose levels. It is therefore important to eat a balanced diet during menopause. Coffee and spicy food stimulate the sympathetic nervous system causing sweating, so they can make some menopausal symptoms worse. Alcohol dilates the blood vessels so will also make flushing and sweating worse. Finally, smoking lowers oestrogen levels, and although the exact mechanism of this isn’t known, quitting may relieve your symptoms.

If you are experiencing menopause symptoms that are making your day to day life difficult, then you should visit your GP to discuss your options. They will tell you whether or not you are a suitable candidate for HRT, or will be able to advise you on alternatives.

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Last updated October 2019
Next update due 2021

Dr. Diana Chiu, MBChB (Hons) MRCP PGCERT (Med Ed) PhD

Diana received her medical degree, with honours, from the University of Manchester. She then went on to receive basic and specialist medical training within the north west of England. She carried out in-depth research in medicine and was awarded a PhD in 2016. Currently, she is finishing her medical training at a large teaching hospital, and one of her greatest interests is medical education. She is an advanced life support instructor and writes regularly for post-graduate examination websites, and also holds a PGCERT in medical education with distinction.

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  2. Valdes, A., and Bajaj, T., ‘Estrogen Therapy’, in StatPearls, Treasure Island, Florida (US), January 2019, [online], (accessed 27 October 2019)
  3. NICE, ‘Menopause’, Clinical Knowledge Summary, National Institute for Health and Care Excellence, March 2017 [online],!prescribingInfoSub:1 (accessed 27 October 2019)
  4. NHS, Overview: Hormone Replacement Therapy (HRT), NHS website, September 2019, [online], (accessed 27 October 2019)
  5. NICE, ‘Menopause’, Clinical Knowledge Summary, National Institute for Health and Care Excellence, March 2017 [online],!prescribingInfoSub:1 (accessed 27 October 2019)
  6. NICE, ‘Menopause: diagnosis and management’, NICE guideline [NG23], National Institute for Health and Care Excellence, November 2015, [online], (accessed 27 October 2019)
  7. Lazovic, G., et al., Tibolone and osteoporosis, Archives of Gynecology and Obstetrics, December 2007, vol 276, no 6, pp 577-581
  8. Formoso, G., et al., Short-term and long-term effects of tibolone in postmenopausal women, Cochrane Review, October 2016, [online], (accessed 27 October 2019)
  9. Archer, D.F., et al., Endometrial Effects of Tibolone, The Journal of Clinical Endocrinology & Metabolism, March 2007, vol 92, issue 3, pp 911-918
  10. Formoso, G., et al., Short-term and long-term effects of tibolone in postmenopausal women, Cochrane Review, October 2016, [online], (accessed 27 October 2019)
  11. Sood, R., et al., Counseling Postmenopausal Women about Bioidentical Hormones: Ten Discussion Points for Practicing Physicians, American Board of Family Medicine, March-April 2011, vol 24, issue 2, pp 202-210
  12. Franco, O. H., et al, ‘Use of plant-based therapies and menopausal symptoms: a systematic review and meta-analysis’, JAMA, 2016, vol 315, no. 23, pp. 2554-63.
  13. Moore, V.,  and Leach, M. J.,  ‘Black cohosh (Cimicifuga spp.) for menopausal symptoms’, Cochrane Database Syst Rev, no. 9, 2012, CD007244.
  14. Teschke, R., et al., ‘Herb induced liver injury presumably caused by black cohosh: a survey of initially purported cases and herbal quality specifications’, Ann Hepatol, vol. 10, no. 3, 2011, pp. 249-59.

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