HRT - hormone replacement therapy - is used by a million women in the UK to address symptoms of menopause. However, the treatment does have its downsides and the UK is currently facing a severe shortage of HRT products. Here we take a look at the natural alternatives. 

August 16, 2019

Hormone replacement therapy provides synthetic versions of the hormones which naturally decline during menopause, usually given in a combined form with oestrogen and progesterone. Many in the medical profession see HRT as a solution for all symptoms of menopause, however, the treatment does have its drawbacks. With over half of the most commonly prescribed products currently out of stock in the UK, we tell you all you need to know about the natural alternatives.

The pros and cons of HRT

Some women swear by HRT and have found great comfort in relief from their symptoms of night sweats, insomnia, continual hot flushes and vaginal dryness. Unfortunately, when you stop taking HRT, you'll go through menopause again as your hormones decline.

HRT may also be prescribed if your doctor believes you are at risk of osteoporosis, due to the effects of oestrogen on supporting bone turnover. However, HRT has been shown to increase your risk of ovarian and breast cancer, with a review in the Lancet in 2015 showing that even short term use of HRT could increase ovarian cancer risk by up to 43%.1

Natural alternatives to HRT

Black cohosh

This medicinal herb has been used for centuries to support menopausal women and is believed to reduce menopausal symptoms through a direct action on the brain, lowering levels of LH (luteinising hormone) to help balance oestrogen and progesterone. It also has an effect on blood vessel dilation, relieving hot flushes, night sweats, low libido, anxiety and mood swings.  

Results from 7 clinical trials involving over 1,000 perimenopausal women aged from 40 to 60 years found that black cohosh extracts produced an average reduction in symptoms of 26% when compared to placebo. This is an impressive result given that the placebo itself was found to reduce severity or frequency of hot flushes by 25% to 30% within 4 weeks of treatment.2

There's been a lot of controversy over this herb, with some calling into question the safety of black cohosh on breast tissue. However, most recent research suggests that black cohosh is a selective oestrogen receptor modulator (SERM), which means that it stimulates only certain oestrogen receptors in the body: namely, the bones and the brain, and not womb or breast tissue. The best way to take black cohosh is as a supplement, and some menopause supporting supplements contain this herb. Or you could visit your local medical herbalist who can make you a bespoke tincture containing black cohosh.

Evening primrose oil

This oil supplies an essential fatty acid called gamma linolenic acid (GLA), one of the few omega-6 fatty acids which has an anti-inflammatory action - similar to that of omega-3s - when intake is sufficiently high. Although your cells produce small amounts of GLA, this process is easily blocked by factors such as increasing age, smoking, pollution, lack of vitamins and minerals and excessive intakes of saturated fat, sugar or alcohol. As a result, deficiency is common and is associated with skin that is itchy, feels rough and dry, and which can become prematurely wrinkled. Evening primrose oil (EPO) becomes incorporated into cell membranes to improve skin quality, smoothness and lustre and is especially helpful to overcome the dryness that accompanies menopause. In addition, EPO may help to improve hormone balance to reduce hot flushes, improve breast tenderness and quality of life. A study involving 56 women found that taking evening primrose oil (1 gram daily) for 6 weeks significantly reduced the severity of hot flushes compared with placebo.3

St John's wort

This popular traditional medicine is sometimes referred to as nature's 'sunshine' herb and is used for boosting mood. St John's wort extract helps to prolong the action of a wide range of neurotransmitters in the brain, including serotonin, noradrenaline, dopamine, gamma-aminobutyric acid (GABA) and L-glutamate . This helps to even out and lift a low mood and anxiety that can accompany menopause. St John's Wort can also improve the psychological and physical symptoms such as hot flushes, low mood, anxiety, low sex drive and exhaustion. In a study involving 111 post-menopausal women with low sex drive, low mood and physical exhaustion, 60% of those taking St John's wort for 3 months regained their sex drive. Eighty-two per cent also suffered a reduction in irritability, anxiety, low mood, hot flushes, sweating and disturbed sleep. Women taking it also report increased self-esteem, self-confidence and self-respect.  If you are taking prescribed medications, it is important to check with a pharmacist for possible drug interactions before starting to take St John's wort.4

Omega 3 essential fatty acids

The signs of omega 3 deficiency are similar to many symptoms experienced during menopause: dry skin, fatigue, depression, and aching joints. Omega 3 essential fats also support hormone balance, and have a lubricating effect in the body, so may help with vaginal dryness, and have been linked to a reduction in risk of breast cancer. Good food sources include oily fish (salmon, mackerel, herring, sardines, seafood and fresh tuna), nuts, seeds and green leafy vegetables.

If you don't like fish, it's worth supplementing fish oil daily. Look for one with at least 200mg of EPA per daily dose. For vegetarians, include flax and chia seeds in your daily diet, and look for a vegetarian omega 3 supplement.

Vitamin D

Many women are prescribed HRT as a prevention for osteoporosis, particularly if they have gone through an early menopause or have had a full hysterectomy. However, supporting bone density doesn't rely on just having the right hormones present. There are key nutrients as well, and vitamin D is one of them. Calcium absorption depends on vitamin D, and it's made through the action of sunlight on the skin. Our ability to absorb it decreases with age, and given the food sources are limited, it's important to supplement. So alongside sensible sun exposure when the sun is out, supplement around 1000-2000 iu per day (25mcg to 50 mcg), of the D3 form, which is better absorbed.

Phytoestrogenic foods

Foods rich in phytoestrogens may help to moderate symptoms of menopause due their effect on oestrogen receptors on the cell membrane. In cases where oestrogen levels are low, they lock into receptors and stimulate a mild oestrogenic effect. Where there is an oestrogen excess, the phytoestrogens block cell receptors. Foods rich in phytoestrogens include soya foods such as miso, tempeh and tofu, lentils, linseeds, sage, mungbeans, garlic, fennel, parsley and celery.

Milk thistle

The active ingredient in milk thistle is a bioflavonoid called silymarin, which can help to support hormonal balance through its protective action on the liver. Any excess hormones we have in our body are detoxified and excreted via the liver and gut, which makes milk thistle an excellent herb to help support hormonal balance, and to help protect ourselves against hormone related female cancers.

For more advice and information about the menopause, please visit our Menopause Advice Centre.


1 Beral, V. et al. (2015). Menopausal hormone use and ovarian cancer risk: individual participant meta-analysis of 52 epidemiological studies. Lancet 385(9980)
2 Shams, T. et al. (2010). Efficacy of black cohosh-containing preparations on menopausal symptoms: a meta-analysis. Altern Ther Health Med 16(1)
3 Farzaneh, F. et al. (2013). The effect of oral evening primrose oil on menopausal hot flashes: a randomized clinical trial. Arch Gynecol Obstet 288(5)
4 Grube, B., Walper, A. and Wheatley, D. (1999). St John's Wort extract: efficacy for menopausal symptoms of psychological origin. Adv Ther 16(4)

Nothing beats a healthy, balanced diet to provide all the nutrients we need. But when this isn't possible, supplements can help. This article isn't intended to replace medical advice. Please consult your healthcare professional before trying supplements or herbal medicines.



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