There are many women who do not wish to risk the side effects HRT (hormone replacement therapy) may bring, or for whom HRT is not prescribed because of their medical history. However, for those who do take HRT, even if they feel great on it, there will be a point at which they need to stop and they will need to physically and emotionally withdraw from the additional hormonal input.
Case Management for Homeopathic Practitioners
I chose to specialise in helping women at menopause because it is an area where homeopathy and a holistic approach has so much to offer women. For me as a practitioner, I find it endlessly fascinating and rewarding to be working with women at this time in their lives.
One of the prevailing challenges is to manage the transition from the patient being on HRT, through the period of dosage reduction, to eventually being comfortably reliant on their own natural hormonal levels. There are also times when due to a pre-existing or emergent health condition the physician stops the patient’s HRT completely and suddenly, which can be very difficult for the woman concerned.
I believe that conscious case management is of immense value in all our work, and for women experiencing difficult symptoms or crisis at the menopause, especially so. It is worth noting that not every woman will struggle at menopause; some sail through or have symptoms that they can manage easily. Within my practice I tend to see those who are having a difficult time and have sought help. Over the years this has given me much experience in this area and I offer you some thoughts and ideas that I hope may be of interest and help in your practice.
I do not intend to delve into materia medica here as this article aims to offer more of an overview of factors to consider, and some supportive strategies with this group of patients. The strategies that follow are intended as broad guides, and however patients present, we can tailor our approach to suit that individual – the joys of an individualistic system of medicine.
Mapping Out the Process
My own approach is to map out the stages with the patient to check that she is happy with the proposed process. To reassure her that there are remedies and support as it unfolds, and that together we will be able to manage the ‘blips’ that may occur as her hormonal levels rebalance.
Once we have taken the case we have a picture of how a patient is experiencing menopause, where her constitutional weaknesses and susceptibilities lie, her family history and any surgical or pharmaceutical interventions. We can then identify her constitutional remedy at this point in time and offer her that bedrock of support – the core and foundation of all our treatment.
Menopause can be a time of immense upheaval on every level – physical, mental and emotional. A time of reckoning when ongoing issues intensify or old and unresolved problems and complaints resurface with a vengeance. The ongoing state of hormonal flux creates its own maintaining cause and I believe there is a good argument for frequent use of specific remedies for helping with issues such as hot flushes, night sweats, joint pains, etc. and organ support remedies alongside the constitutional remedy.
Utilising Organ Support Remedies
I believe it can be particularly helpful to identify which areas of organ support would be most beneficial.
- Liver Support – traits that suggest liver support would be helpful (sluggish, intolerance of fats, chilly, difficulty in waking in the morning, etc.), a history of dietary or lifestyle factors that give the liver more work to do, a history of moderate to high intake levels of prescribed or over-the-counter pharmaceutical medications.
Good liver function at menopause supports hormonal balance, temperature regulation, and blood sugar metabolism – all key at this life stage.
- Adrenal Support – a history of acute or extended stress, someone who “lives on their nerves”, or takes medication such as HRT or other steroids which can deplete the adrenals. Good adrenal function supports long term overall health, vitality and immune function in addition to being a source of peri and post-menopausal oestrogen.
- Cardiovascular Support – is there a history or family history of cardiovascular complaints? Good cardiovascular health is a cornerstone for us all and conditions can become more pronounced at menopause.
- Current or family history of Osteoporosis – is there a family history or any current issues around bone health? Osteoporosis is increasing, not solely, as some would have us believe, as a direct consequence of menopause, but as a result of lifestyles that promote its occurrence. It is useful to know whether a patient is worried about osteoporosis because she has had bone scans that indicate an issue, or has one or more of the risk factors listed below.
- Risk Factors for Osteoporosis include: it is useful to know whether a patient is worried about osteoporosis because she has had bone scans that indicate an issue, or has one or more of the following risk factors. Family history, history of an eating disorder, irregular periods, smoking, low or very high levels of exercise, being underweight, digestive problems that affect absorption (e.g. low hydrochloric acid levels, coeliac disease), an early menopause, being European or Asian, some medications – steroids, laxatives, diuretics, some thyroid medications, drugs for blood thinning such as Heparin.
- Bone Health – for many women, following sound dietary advice, taking supplements, not smoking or having an excessive alcohol intake, and avoiding sedentary lifestyles may be helpful in reducing the risk of osteoporosis. For those with a strong family history, a current condition or a number of risk factors, there is also a great deal of additional positive support that can be offered.
Suitable organ support remedies can then be prioritised and factored in as herbs or low potency remedies as preferred at the relevant stages as treatment progresses. If using herbs you will need to check there are no contra-indications with any medical conditions or pharmaceutical medicines the patient is taking.
Strategies for HRT Withdrawal
The Patient is Currently Taking HRT and Wishes to Stop
Stage One: Preparation – if possible suggest the patient does not stop straight away. This is where we build a platform underneath the patient so that when she stops HRT she is supported by constitutional and where relevant, organ support remedies. The patient needs to discuss with their doctor that they wish to reduce their HRT gradually (usually around 1-2 months depending upon how severe the symptoms were initially).
- Develop a clear overall constitutional picture – you may find that she presents a different constitutional picture whilst on HRT, and I would prescribe on how she is now whilst also gaining insights about her constitution before HRT. It is good to gather as much information on the pre-HRT menopausal symptoms as you can, and to have suitable remedies for these ready and waiting should these return.
- Consider adrenal support – Adrenal Gland 6c daily and/or Avena Sativa in low potency, such as 3x or 6c, or as a herbal tincture.
- Consider liver support to help in the detoxification and elimination of old/excess oestrogen. Milk Thistle (Carduus Marianus) is an excellent herb for supporting liver function.
- Consider bone health support if needed – alongside all the dietary and lifestyle measures there are also specific nutritional supplements and remedies for promoting bone health. Homeopathically I have used a number of combinations; my favourite is Calc-Fluor, Calc-Phos, Silica and Conchiolinum (mother of pearl) in a low potency (6x – 6c) three times daily – long term. You may wish to check any contraindications for Silica in terms of any clips, pins, implants or stents, etc. that may be part of the patient’s medical history. In this case, I simply omit it from the combination. Where there has been a history of bone breaks/fracture Symphytum can also be added.
- You can also consider a single dose of Parathyroid 30c once a week for three weeks repeating a single dose at monthly or longer intervals as needed to support the parathyroid in the regulation of calcium levels.
- Cardiovascular support if there is a history or family history. In addition to constitutional remedies that have an affinity with the cardiovascular system, also consider Hawthorn (Crataegus Oxyacanthoides) tincture – a wonderfully gentle herb that supports patients with high blood pressure and cholesterol issues.
- Depending upon how they have responded to the HRT (and similar medications such as the Pill, Mirena Coil, or fertility drugs) consider Sepia, Pulsatilla and Folliculinum to support their hormonal rebalancing.
- Review what foods to eat during menopause, supplements and lifestyle measures (sleep, relaxation, exercise, fun and creativity) to see where support could be gained.
Stage Two: Transition – once we feel that we are ready, I usually suggest reducing the HRT gradually over a period of weeks, sometimes months.
- Continue constitutional support and add in specific remedies to help with oestrogen withdrawal symptoms as needed. These might be additional remedies for hot flushes, etc.
- Continue and adapt organ support
- Do not use the hormonal balancing herbs in their crude herbal form yet. Principally Agnus Castus and Black Cohosh as they will be at odds with the HRT.
Stage Three: and beyond…once off HRT the true current picture will become clear and we can adapt our prescribing accordingly. In my experience, it is quite common for symptoms to settle, change and flare up from time to time as the hormonal equilibrium shifts.
- Add in hormonal balancing and support herbs, this should provide extra support in terms of reducing the oestrogen withdrawal symptoms.
- At each stage and appointment, review how the constitutional and specific remedies are helping, revisit dietary and lifestyle measures as appropriate.
The Patient is Experiencing Symptoms after Stopping HRT
Women may contact us at this stage in desperation as they have come off HRT voluntarily, but often because of concerns over their health, or at their GP’s recommendation, and they may be experiencing severe symptoms. In this situation, I will usually put all my emphasis on to reducing the symptoms and revisit the long-term organ support once the acute urgency has diminished.
- Use hormonal balancing and support herbs.
- Constitutional and specific remedies to support with symptoms such as hot flushes and night sweats – using higher potencies if symptoms are frequent and intense.
- Stress the positive and immediate impact of dietary changes.
When the Patient Cannot Take HRT
Despite its many documented risks and the guidelines to only prescribe short-term where symptoms are severe, I believe it is still over-prescribed. Currently, it is mainly women with medical histories or strong family histories that include cardiovascular complaints or cancer who will usually be advised by their GPs not to take HRT. I have worked with a number of women who would normally never have considered homeopathy but for this. It is a wonderful opportunity to help and to demonstrate how much this elegant and gentle system of medicine has to offer. Generally, their symptoms are severe enough to generate impetus for them to contact us, so I would focus my prescribing around symptomatic relief before moving on to address long-term support both menopausal and general.
In addition, I would suggest that women with a history of conditions fuelled by oestrogen such as fibroids and endometriosis consider very carefully any offer to take or to resume HRT treatment. Even if years have passed and organs or tissue have been removed, in homeopathic terms their constitution clearly has a tendency to create ‘growths’, in these instances in hormone-sensitive tissue. Fuelling that tendency with oestrogen seems to me to be a high-risk strategy.
If there are cardiovascular concerns I may add Crataegus Oxyacanthoides (Hawthorne) into the herbal combination and use constitutional and specific remedies to support. If there is a history of cancer, many patients will have been told not to take herbs or eat soya, and to avoid phytoestrogenic herbs and supplements, etc. In this instance, the fear is often understandably so pronounced, and I have no desire to add to that, I will just work with homeopathic remedies, general dietary advice and supplements as appropriate.
Menopause as an Opportunity
Menopause is a vast and complex arena in which the patient and practitioner are presented with both challenges and opportunities. HRT, whether standard or bio-identical HRT, may mask a woman’s true health and connection with her deeper self. Avoiding taking HRT or withdrawing from it gives women the chance to address immediate and long standing health and life issues. To move forwards into the decades ahead happier and healthier. It is a privilege to accompany them on this part of their journey.