What non-hormonal alternatives are available for patients who cannot or choose not to use HRT?

For patients who are unable or choose not to use hormone replacement therapy (HRT), several non-hormonal alternatives are available for managing menopausal symptoms.

• Cognitive behavioural therapy (CBT): Menopause-specific CBT can be offered for vasomotor symptoms, difficulties with sleep, or depressive symptoms associated with menopause. It can be used alone or alongside other treatments, especially when HRT is contraindicated or declined.
• Non-hormonal vaginal treatments: For genitourinary symptoms, non-hormonal vaginal moisturisers and lubricants can be used alone or in combination with vaginal oestrogen. If vaginal oestrogen is contraindicated or not tolerated, these non-hormonal options are recommended.
• Oral selective estrogen receptor modulators (SERMs): Oral ospemifene may be considered for moderate-to-severe genitourinary symptoms if local vaginal treatments are impractical or contraindicated.
• Complementary therapies: Some evidence suggests that isoflavones or black cohosh may relieve vasomotor symptoms, but their safety and efficacy are uncertain, and preparations vary widely.
• Psychological interventions: Psychological therapies have been reviewed for menopausal symptom relief and may be considered as part of a holistic approach.
• Pharmacological options: Although selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs) and clonidine are not recommended as first-line treatments for vasomotor symptoms alone, they may be considered in specific cases under specialist advice.

These options provide alternatives for symptom management when HRT is unsuitable or declined, with the choice tailored to individual preferences, symptom severity, and contraindications.

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