Medically Reviewed by Dr. Tashiya Mirando, MD, Written by Swati Pund, PhD
Menopause is a natural phase in a woman’s life, but the hormonal changes it brings can lead to a range of challenging symptoms. As estrogen and progesterone levels decline, many women experience hot flashes, night sweats, mood swings, joint pain, memory changes, and vaginal or urinary discomfort. Menopause hormone therapy (MHT) is a widely used treatment to alleviate these symptoms by replenishing the hormones your body no longer produces in sufficient amounts.
This blog post will explore the types of menopause hormone therapy available (with over 50 combinations currently on the market), their benefits, and the safety considerations to help you make informed decisions about managing menopause symptoms.
What is Menopause Hormone Therapy?
MHT is a broad term that refers to treatments involving estrogen alone (estrogen therapy, or ET) or a combination of estrogen and progesterone (estrogen-progestogen therapy, or EPT). These therapies are designed to address the hormonal imbalances that occur during menopause.
While commonly known as “Hormone Therapy” in North America, you may also hear it referred to as “Hormone Replacement Therapy (HRT)” or “Menopause Hormone Therapy (MHT)” in other regions.
Types of Menopause Hormone Therapy
Menopause hormone therapy for menopause comes in various forms, each tailored to address specific symptoms and health needs. Understanding the differences between estrogen therapy (ET), estrogen-progestogen therapy (EPT), and progestogen therapy can help you make informed decisions about managing menopause effectively.
1. Estrogen Therapy (ET):
This is typically prescribed for women who have undergone a hysterectomy (removal of the uterus). ET is available in various forms, including pills, patches, gels, creams, sprays, and vaginal rings. It effectively relieves most menopausal symptoms and can also help reduce the risk of osteoporosis.
Systemic ET: Delivers estrogen throughout the body to manage widespread symptoms like hot flashes and bone loss.
Local ET: Uses low-dose vaginal estrogen to specifically address vaginal and urinary symptoms without the need for additional progestogen.
2. Estrogen-Progestogen Therapy (EPT):
Women who still have their uterus need to take progestogen alongside estrogen to protect the uterine lining. Estrogen alone can thicken this lining, increasing the risk of endometrial cancer. Progestogen mitigates this risk but does not protect against other types of uterine cancer.
Cyclical/Sequential EPT: Involves taking progestogen for 10–14 days each month, often resulting in withdrawal bleeding after the end of each course. This approach is suitable for women who are still experiencing periods (perimenopausal).
Continuous Combined EPT: Provides a steady dose of both hormones, eliminating monthly bleeding. This option is recommended for postmenopausal women who have gone at least a year without a period. Research indicates continuous combined therapy may lower the risk of endometrial cancer more effectively than cyclical regimens.
3. Progestogen Therapy:
Progestogens encompass both natural progesterone and synthetic progestins. They are primarily used to protect the uterus from the cancer risk posed by unopposed estrogen therapy.
While progestogen therapy is usually part of combined menopause hormone therapy with estrogen, it is not commonly used by itself to manage menopausal symptoms. One notable exception is the Mirena intrauterine system, which releases progestogen directly into the uterus, offering both uterine protection and control of bleeding. This device can be effective for up to 5 years, allowing flexibility in estrogen dosing.
Biologically similar to progesterone, Micronized progesterones are naturally produced by the ovaries. This may carry fewer risks related to blood clotting and breast cancer, although the evidence—particularly regarding breast cancer—is not definitive.
Whether you’re considering ET, EPT, or progestogen therapy, the choice depends on your medical history, symptoms, and individual health risks.
Why Consider Menopause Hormone Therapy?
Hormone replacement therapy can relieve various symptoms caused during menopause and postmenopause:
- Alleviate night sweats and hot flashes
- Improve mood disturbances and memory changes
- Reduce muscle and joint pain
- Ease vaginal and urinary discomfort
There are more than 50 different combinations of hormones available, administered through various routes such as oral tablets, patches applied to the skin (transdermal), long-lasting implants placed under the skin (subcutaneous), or local/vaginal delivery methods. Finding the right type and dose of hormones at the right time can help restore quality of life while minimising risks.
How is MHT Administered?
MHT can be delivered in several ways, depending on your needs and preferences:
- Oral tablets: Convenient but may not be suitable for women with a history of blood clots or severe liver disease.
- Transdermal patches/gels/sprays: Absorbed through the skin, these methods bypass the liver and may reduce certain risks, such as stroke.
- Vaginal creams/rings: Ideal for addressing localized symptoms like vaginal dryness.
- Subcutaneous implants: Long-lasting but less commonly used.
The method should be chosen based on your health profile, symptom severity, and personal preferences, ensuring both effectiveness and safety.
Safety Profiles of Menopause Hormone Therapy
The safety of MHT depends on factors like the type of hormones used, the method of administration, the timing of treatment, and individual health risks. There are some key considerations to be made before opting for any type of MHT:
1. Timing Matters
Starting MHT before age 60 or within 10 years of menopause onset is associated with lower risks and greater benefits, including potential protection for heart and bone health. For women over 60, transdermal patches or gels are strongly preferred over oral tablets due to their safer risk profile.
2. Risks to Be Aware Of
While MHT can be highly effective for managing menopause symptoms, it’s important to understand the potential risks associated with its use:
- Venous Thromboembolism (VTE): A rare but serious risk, particularly with oral estrogen.
- Gallbladder Issues: Slightly increased risk with estrogen use.
- Stroke: The risk is higher with oral estrogen but may be reduced with transdermal methods.
- Breast Cancer: EPT has been linked to a small increase in breast cancer risk, though micronised progesterone may be safer in this regard but the results are apparently inconclusive.
By being aware of these risks and discussing them with your healthcare provider, you can make informed decisions to balance the benefits and safety of menopause hormone therapy.
3. Special Populations
For women with a history of cancer, menopause hormone therapy requires careful consideration, as risks and benefits vary significantly depending on the type and stage of cancer:
- Breast Cancer Survivors: While systemic menopause hormone therapy is generally not recommended, low-dose vaginal estrogen may be safe for managing local symptoms. In cases of severe symptoms, systemic therapy might be considered under close monitoring and with oncologist approval.
- Endometrial Cancer Survivors: Systemic menopause hormone therapy is typically avoided, particularly in high-grade, advanced-stage cases. The risks and benefits must be carefully evaluated for each individual case.
- Ovarian Cancer Survivors: While the benefits generally outweigh the risks for many types of ovarian cancer, hormone replacement therapy is typically avoided in hormone-dependent types such as granulosa-cell tumors and low-grade serous carcinoma. For other types, menopause hormone therapy may be considered after careful evaluation.
Understanding the safety profiles of any therapy is essential, as risks and benefits vary based on individual health factors, timing, and treatment methods—making personalised medical guidance crucial for safe and effective use.
Conclusion
MHT can be a highly effective way to manage menopause symptoms and improve quality of life. However, it’s not a one-size-fits-all solution. By understanding the types of therapy available, their benefits, and potential risks, you can work with your healthcare provider to make an informed decision that aligns with your health goals.
If you’re considering menopause hormone therapy, consult a menopause specialist to discuss your options and create a personalised plan.
References
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