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Menopausal Hormone Therapy (MHT)
An Overview of Menopausal Hormone Therapy
What is Menopause Hormone Therapy (MHT)?
Menopause Hormone Therapy (MHT), also referred to as Hormone Replacement Therapy (HRT), is a medical treatment used to manage the symptoms of menopause. It works by replacing the hormones—primarily estrogen and progesterone—that the body produces in lower amounts after menopause. Menopause marks the end of a woman’s reproductive years, typically occurring between ages 45 and 55, and it is characterized by the cessation of menstrual cycles and a reduction in hormone production.
MHT is designed to help alleviate common menopausal symptoms such as hot flashes, night sweats, mood changes, sleep disturbances, and vaginal dryness. In addition, it can help prevent long-term health conditions associated with menopause, such as osteoporosis and heart disease, by providing hormonal support.
Types of Menopause Hormone Therapy
- Estrogen Only Therapy: Estrogen is the builder hormone, so replacement in women who are low improves their mood, energy, muscle mass, bone density and vaginal health. It also very much supports cardiovascular health if hormone therapy starts no more than 10 years after the last period. It is typically recommended for women who have undergone a hysterectomy (removal of the uterus) because it does not increase the risk of endometrial cancer in the absence of the uterus.
Combined Estrogen and Progesterone Therapy: For women who still have their uterus, estrogen unopposed by progesterone can lead to endometrial hyperplasia, and possibly endometrial cancer. Estrogen is therefore never prescribe on its own for a woman with a uterus, both estrogen and progesterone (or progestin, a synthetic version) are used. Progesterone however can very much improve perimenopausal symptoms of insomnia and anxiety, so its addition to a treatment plan is usually not just for protection against endometrial cancer.
Progesterone Only Therapy: Progesterone alone is often the first MHT prescription given, as it tops up the declining progesterone levels. In most cases, progesterone drops initially, later followed by estrogen. We are constantly straddling the balance between estrogen and progesterone levels.
Local Estrogen: For women experiencing vaginal dryness or urinary issues, local estrogen therapy (in the form of creams, rings, or tablets) may be recommended. This allows for estrogen to be delivered directly to the affected area with minimal systemic absorption. At this correct dose, even women with a history of cancer may consider this option to alleviate vaginal symptoms of menopause.
How Menopause Hormone Therapy Works
Menopause leads to a natural decline in reproductive hormones, especially with estrogen fluctuating wildly. This change in estrogen can result in a range of symptoms, including hot flashes, night sweats, mood swings, vaginal dryness, and reduced bone density. MHT works by replenishing and balancing hormone levels to alleviate these symptoms and help maintain hormonal equilibrium.
For women with intact uteruses, progesterone is added to the therapy to reduce the risk of endometrial hyperplasia (overgrowth of the uterine lining), which can lead to cancer if left untreated. MHT is typically administered through pills, patches, gels, creams, or vaginal inserts, and the delivery method can be tailored based on the patient’s specific needs, preferences and risk factors. Oral estrogen is absolutely contraindicated, and is applied topically as a gel, cream, or patch. Progesterone can be administered topically, but more often is prescribed vaginally or orally.
Benefits of Menopause Hormone Therapy
MHT has both short-term and long-term benefits for women going through menopause.
Short-Term Benefits of MHT:
Relief from Vasomotor Symptoms: The most common and bothersome symptoms of menopause are hot flashes and night sweats. MHT is highly effective in reducing the frequency and severity of these symptoms.
Improved Sleep: Many women experience sleep disturbances due to hot flashes and night sweats. MHT can improve sleep quality by reducing these symptoms.
Enhanced Mood: Hormonal fluctuations during menopause can contribute to mood swings, anxiety, and depression. MHT helps stabilize mood by restoring hormonal balance.
Improved Vaginal Health: Estrogen therapy can improve vaginal dryness, itching, and discomfort, as well as reduce urinary issues associated with menopause.
Better Sexual Function: By alleviating vaginal dryness and enhancing libido, MHT can help improve sexual satisfaction.
Long-Term Benefits of MHT:
Prevention of Osteoporosis: Estrogen helps maintain bone density. Postmenopausal women are at increased risk of osteoporosis due to the loss of estrogen. MHT can help prevent bone loss and reduce the risk of fractures.
Cardiovascular Health: Estrogen has a protective effect on the cardiovascular system, and MHT can help reduce the risk of heart disease, particularly if started soon after menopause.
Skin and Hair Health: Estrogen helps maintain skin elasticity and hair thickness, so MHT may reduce the appearance of skin aging and hair thinning.
Risks of Menopause Hormone Therapy
While MHT offers significant benefits, it also carries potential risks that must be considered before starting treatment. It is important for each woman to consult with her healthcare provider to weigh the risks and benefits based on her medical history and individual health needs.
1. Breast Cancer Risk
One of the most discussed risks of MHT is its potential association with breast cancer. Research has shown that combined estrogen and progesterone therapy (especially oral forms) may slightly increase the risk of breast cancer, particularly with long-term use. However, the risk appears to be lower for women who use bioidentical hormones, for those who start MHT closer to the time of menopause, and when estrogen is administered topically.
According to the British Menopause Society (BMS), the breast cancer risk is greatest for women who use combined hormone therapy for more than five years. The Menopause Society in the U.S. similarly notes that the risk is lower for women using hormone therapy for a shorter duration, and the decision to use MHT should be individualized.
2. Blood Clots and Stroke
Oral forms of estrogen therapy can increase the risk of venous thromboembolism (blood clots) and stroke, particularly in women who are older, obese, or have a history of blood clotting disorders. Transdermal estrogen (delivered through patches or gels) is generally considered safer in this regard, as it does not carry the same increased risk of blood clots.
The Menopause Society and BMS both recommend careful screening for these risks, particularly in women who are older or have risk factors for cardiovascular disease or clotting disorders. No evidence-based, well informed licensed health care provider will prescribe oral estrogen for menopausal hormone therapy at this point.
3. Endometrial Cancer
For women who have not had a hysterectomy, estrogen therapy alone can increase the risk of endometrial cancer (cancer of the uterine lining). This is why progesterone is always added to MHT in women with intact uteri to protect against this risk.
Studies have shown that the addition of progesterone significantly reduces this risk, which is why combined hormone therapy is recommended for most women who have a uterus.
Current Research and Guidelines
The British Menopause Society (BMS) and The Menopause Society (USA) provide evidence-based guidelines for the use of MHT. Both organizations emphasize that the decision to use hormone therapy should be individualized and made after a thorough discussion of the risks and benefits with a healthcare provider.
Key Points from the British Menopause Society (BMS) and NICE Guidelines:
MHT is considered safe for most women under the age of 60 or within 10 years of menopause onset. The risks associated with hormone therapy increase with age and time since menopause.
For women with symptoms of menopause, MHT remains the most effective treatment for hot flashes, night sweats, and vaginal dryness.
Key Recommendations from the Menopause Society:
Women should receive personalized counseling regarding MHT, including a review of their individual health history, family medical history, and risk factors.
Transdermal and low-dose therapies are preferred for women who need estrogen but wish to minimize risks like blood clots or stroke.
Women who choose MHT should aim for the shortest duration necessary to manage symptoms, and periodic reassessment is recommended.
Should You Consider Menopausal Hormone Therapy?
Menopause Hormone Therapy remains a cornerstone in the management of menopause symptoms and the prevention of long-term health risks, such as osteoporosis and cardiovascular disease. However, its use must be carefully tailored to the individual, considering the potential risks, including breast cancer, blood clots, and cardiovascular issues.
Guidelines from the British Menopause Society (BMS) and The Menopause Society emphasize a personalized, patient-centered approach. Women should be thoroughly evaluated, and any decision to start MHT should involve a discussion of both the potential benefits and risks, along with the consideration of alternative treatments, lifestyle modifications, and natural therapies.
By staying informed about the latest research and medical standards, women can make empowered decisions about managing menopause and improving their quality of life during this significant life transition.
Menopausal Hormone Therapy Links & Resources
The Details Of Bioidentical Hormones | The Process
The Benefits of Menopausal Hormone Therapy: Short and Long-Term Advantages
3 Things You Need To Know About Hormone Therapy In Menopause
FACTSHEETS: From the Newson Menopause Society
Breast Cancer Risk in Hormone Therapy
HRT and breast cancer: overall risks and benefits explained | British Menopause Society
Hormone Therapy: Understanding the Risks and Benefits | Menopause Society
Your Doctor: Meet Dr. Sarah
Dr. Sarah Goulding is a licensed naturopathic doctor in Ontario and has a BSc in neuroscience and biology from Dalhousie University (2004), and did her 4-year naturopathic training at the Canadian College of Naturopathic Medicine (2010). She’s since accumulated over a decade of clinical experience, and refined her practice to focus on women’s health and digestion. She is licensed and registered as a Naturopathic Doctor in Ontario by The College of Naturopaths of Ontario (CONO) and is a member of the Canadian Association of Naturopathic Doctors (CAND) and the Ontario Association of Naturopathic Doctors (OAND).
Dr. Sarah Goulding blends science and compassion, and acts as a personal health researcher to help you navigate your health. Tools that she uses include nutrition, supplements and botanicals, bioidentical hormones, and lifestyle modifications. The closer you get to the root cause, the gentler the therapies needed to resolve the issue.
