Menopausal hormone therapy

MHT contains different hormones – oestrogen, progestogen or both. MHT  can be taken or used in different ways such as tablets, patches or gel.

The type of MHT needed, and any associated risk, varies according to your age, whether you have had an operation to remove your womb or uterus (hysterectomy) and whether you have other health conditions. Talk to your healthcare provider about your symptoms and your personal medical history. This will guide the treatment best suited to you.

• If you’ve had a hysterectomy (your uterus has been removed), you can use oestrogen and you don’t need progestogen. 
• If you have a uterus, it’s important that you use both oestrogen and progestogen for your MHT. Taking oestrogen alone can cause thickening of the uterus lining (endometrium) which can increase the risk of endometrial cancer. Taking progestogen helps to prevent the thickening of the lining and therefore reduces the risk of cancer.

Oestrogen tablets, patches and gel are absorbed into your bloodstream and can work in hormone receptors in different parts of the body including your uterus (womb), bladder, heart, bones, skin, muscles and brain.

If your symptoms are mainly related to vaginal dryness, urinary symptoms and pelvic floor problems, applying oestrogen to your vagina, in the form of vaginal cream or pessaries, may be more suitable. It's designed to work mainly in your vagina, bladder and pelvic floor. They can help reduce your risk of UTIs as well as helping with vaginal symptoms. They are very safe, even if you've had breast cancer. Read more about oestrogen vaginal cream and pessaries.

Read more about the different types of MHT below.

MHT contains different hormones – oestrogen, progestogen or both. MHT can be taken or used in different ways such as tablets, patches or gel.

Oestrogen alone

Oestrogen alone is suitable if you've had an operation where your uterus has been removed (hysterectomy).

Oestrogen is available as different products and in different strengths.

• Tablets such as Progynova, Estrofem, Ovestin, Premarin.
• Patches such as Estradiol, Estradot and Estraderm MX, Lyllana Estradiol.
• Gel such as Estrogel.

Safety considerations of oestrogen alone

• Blood clots: Oestrogen patches and gel have minimal or no risk. When using tablets, the risk doubles, but it's still very low (1 extra blood clot per 1000 women).
• Heart disease: MHT may decrease the risk of heart disease if started within 10 years of menopause or before the age of 60.
• Breast cancer: Overall 1 in 8 women will develop breast cancer during their lifetime. Studies suggest there's either no increase, or a very small increased risk of breast cancer when using oestrogen only MHT. Breast cancer risk is lower with oestrogen only MHT compared with oestrogen plus progestogen. Read more about breast cancer risk(external link). 
• Stroke: There's no increased risk if you don’t already have risk factors for stroke and you're in your 50s or during the first 10 years of menopause. If you have risk factors you can probably still safely use oestrogen patches or gel.

Vaginal oestrogen cream or pessaries (Ovestin cream® and Ovestin pessaries®)

If your symptoms are mainly related to vaginal dryness, urinary symptoms and pelvic floor problems, applying oestrogen directly to your vagina may be more suitable.

• It's designed to work mainly in your vagina, bladder and pelvic floor.
• The oestrogen levels in your blood aren't raised significantly, which minimises the effect of oestrogen in other areas such as the breast or uterus.
• Vaginal oestrogen can be used alone or with MHT.
• It doesn't need to be used with any progestogen even if you still have a uterus. Read more about oestrogen vaginal cream(external link).

Oestrogen plus progestogen

If you still have your uterus, your MHT will include both oestrogen and progestogen. This is because oestrogen alone can overstimulate the cells lining your uterus, causing an increased risk of cancer of the uterus lining. So if you have a uterus you will need to take progestogen together with oestrogen to reduce the risk.

Example of progestogen only products include:

• Tablets: Norethisterone (Primolut N), medroxyprogesterone (Provera)
• Capsules: Utrogestan
• Intrauterine device (IUD): Mirena

You will need to take these with oestrogen only products. Some products have both oestrogen plus progestogen in a single tablet such as Kliogest, Kliovance and Trisequens.

Safety considerations of oestrogen plus progestogen

• Blood clots: Patches and gel have minimal or no risk. When using tablets the risk doubles, but it's still very low (1 extra blood clot per 1,000 women).
• Heart disease: There's no increased risk if MHT is started within 10 years of the start of menopause or before the age of 60.
• Breast cancer: Overall 1 in 8 women will develop breast cancer during their lifetime. The added risk of breast cancer with MHT is very small. The risk increases the longer you take MHT and decreases after stopping it. Some types of progestogens have lower risk.
• Stroke: There's no increased risk if you don’t already have risk factors and you're in your 50s or during the first 10 years of menopause. If you have risk factors you can probably safely use a patch.
• MHT with oestrogen and progestogen doesn't cause weight gain.

Tibolone (also called Livial)

Tibolone isn’t oestrogen or progestogen, but it has similar effects. Tibolone can be used if you still have your uterus and haven't had a natural period for at least 1 year. It comes as a tablet that's taken once a day.

Note: Tibolone is not funded in Aotearoa New Zealand.

• Tibolone can reduce the risk of osteoporosis (thinning of the bones) in post-menopausal people.
• It doesn't cause an increase in blood clots, heart disease or breast cancer. It reduces breast tenderness and there is no evidence of an increase in breast cancer risk with 3 years of use.
• It increases the risk of stroke if started after the age of 60.
• Read more about tibolone.(external link)

MHT is safe to use for most people if started in their 50s or for the first 10 years after the onset of menopause.

If you had an early menopause (before 45 years) you should continue treatment at least until the average age of menopause (51 years).

Note: If you have had hormone-dependent cancer, you shouldn't use hormone therapies. Talk to your doctor about menopausal non-hormone therapies.

Combined MHT (oestrogen plus progestogen) or oestrogen alone cause no significant increase in breast cancer or heart disease risk in women aged 50 to 59 or in women who start treatment within 10 years of menopause. There are lots of myths and misunderstanding about MHT. Read more about myths and misunderstandings of MHT(external link).

When assessing the risks of MHT, remember that they're not the same for everyone. Your healthcare provider will be able to discuss your individual risk with you.

• Risks vary based on how old you are, when you start MHT and how long you take it for.
• Short-term use in early menopause has fewer risks than when it's started later in menopause.
• Risks generally increase as you get older.

Most MHT options do not provide contraception. Contraception is still recommended for 2 years after your last period if you're under the age of 50, and for 1 year after your last period if you're over 50.

• A Mirena IUD (contraceptive device that sits in the uterus) works as contraception to prevent pregnancy. It can also provide the progestogen component of MHT.
• Ask your doctor or nurse prescriber about suitable contraception options if needed.

• Every person is different and the length of time you'll have menopausal symptoms is unknown.
• People who go through menopause before 45 years of age are advised to take oestrogen therapy until the average age of menopause – about 51 years of age.
• It’s important to have regular check-ups with your doctor to assess whether ongoing MHT is right for you.
• MHT is safe to use for most people in their 50s or for the first 10 years after the onset of menopause.
• Most people stop taking it after a few years, when their symptoms improve. It's usually best to reduce MHT gradually rather than stopping it suddenly. This may reduce the risk of menopausal symptoms returning.

Many people consider using complementary therapies such as phytoestrogens.

• Some complementary medicines may help some people with mild symptoms, but there is little clinical evidence to support their use.
• Avoid buying online products – their safety can't be guaranteed.
• You shouldn't use soy/phytoestrogen products if you can’t take prescribed hormone therapy for safety reasons (eg, breast cancer).
• Complementary therapies can also cause side effects and may interact with prescription medicines, so tell your doctor, nurse prescriber or pharmacist if you're using or planning to use these.
• Read more about complementary medicine options for menopausal symptoms(external link).

You may want to consider non-hormonal treatments if you don't want MHT, or you're unable to take it. There are some lifestyle changes such as improving your diet, exercising and stopping smoking which may help to reduce your menopausal symptoms.

Other possible treatments for menopause symptoms include:

• Some antidepressants (usually low doses) can help with severe hot flushes and sweats.
• Other medicines may help with severe hot flushes and sweats. Talk to your doctor or nurse prescriber about these.
• High blood pressure medication can help with mild menopausal symptoms.
• Psychological techniques including mindfulness, cognitive behavioural therapy (CBT) and hypnosis have some evidence for improving hot flushes and night sweats

Talk to your doctor or nurse prescriber if you want to explore any of these options. Read more about menopausal non-hormone therapy.