Menopausal hormone therapy

You may be more familiar with the term hormone replacement therapy or HRT.

• Hormone replacement therapy used for relieving symptoms of menopause, is now called menopausal hormone therapy or MHT.
• Hormone replacement therapy or HRT is now the term for when treatment is used to replace oestrogen in other situations, where menopause is not the cause.

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

The type of MHT needed and any risks 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.

If you have menopausal symptoms that affect your quality of life and want to know what treatments could help, talk to your healthcare provider. The following is some guidance.

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: 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.
• 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 a patch.

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. There's no increased risk of blood clots, so you don't need to use progesterone. 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 progesterone 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 progesterone doesn't cause weight gain.

Tibolone (also called Livial)

Tibolone isn’t oestrogen or progesterone, 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)

Most people manage their menopause symptoms themselves, but if symptoms are affecting your quality of life, see your doctor or nurse prescriber about possible treatment options.

MHT has been found to:

• reduce the number and severity of hot flushes and night sweats
• improve symptoms of vaginal dryness and soreness
• help reduce recurrent urine infections
• lower the risk of osteoporosis, because oestrogen slows bone thinning and helps increase bone thickness.

MHT may also reduce the risk of diabetes and heart disease for some people.

Without treatment, menopausal symptoms such as hot flushes, night sweats, sleep problems and headaches may last for a few years. About 10% of women still have symptoms  that bother them 10 years after their last period.

Different types of MHT have different risks. 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.

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.

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.

• Most MHT options do not provide contraception.
• A Mirena IUD (contraceptive device that sits in the uterus) works as contraception to prevent pregnancy. It can also provide the progesterone 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.