Menopausal hormone therapy

Previously called HRT or hormone replacement therapy

Key points about menopausal hormone therapy (MHT)

  • Menopausal hormone therapy (MHT) is the use of hormone therapy (tablets, patches or cream) to replace the oestrogen that your ovaries no longer make during and after menopause.
  • It can help relieve some of the symptoms of menopause.
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Menopause occurs as the amount of oestrogen produced by a woman’s body slowly reduces over time. Leading up to menopause is a phase called peri-menopause which may take a number of years. Both peri-menopause and menopause cause similar symptoms which affect multiple areas of the body, and can significantly affect your quality of life. Read more about menopause.

Menopausal hormone therapy (MHT) is the use of hormones (tablets, patches, creams or pessaries) to replace oestrogen. Your ovaries are no longer making oestrogen during peri-menopause and after menopause. It can help to relieve some of the symptoms of menopause and can make a big difference to the enjoyment of life for some people.

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 is now the term for when it's used to replace oestrogen in other situations, where menopause is not the cause.

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. 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.

Different types of MHT have different risks. When assessing the risks associated with MHT, remember that they're not the same for everyone. Your healthcare provider will be able to discuss your individual risk in more detail.

  • 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.

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 Estradot, Climara, Estraderm.
  • Vaginal cream or pessaries such as Ovestin. Read more about vaginal oestrogens.

Vaginal cream or pessaries are useful if you have symptoms affecting your vagina such as vaginal dryness, burning or itching or recurrent urine infections (UTIs). This therapy is safe to use long-term, as long as you haven’t had breast cancer.

Safety considerations of oestrogen alone

  • Blood clots: patches and cream or pessaries 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.

Oestrogen plus progestogen

If you still have your uterus, your menopausal hormone therapy 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.

Example of progestogen only products include:

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 creams or pessaries 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 does not cause weight gain.

Oestrogen plus bazedoxifene (also called Duavive)

Duavive tablets are a combination of oestrogen plus a non-hormone medicine, bazedoxifene. It's an option if you have a uterus but progestogen is unsuitable for you.

  • Duavive improves menopause symptoms, increases bone density and reduces breast density. It also reduces the risk of cancer of the lining of the uterus (endometrium) if you still have your uterus.

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.

  • 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)

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) can also provide the progesterone component of MHT, and also works as contraception to prevent pregnancy.
  • Ask your doctor or nurse prescriber about suitable contraception options if needed.

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).
  • All complementary therapies can also cause side effects and may interact with prescription medicines, so tell your doctor, nurse prescriber or pharmacist if youu'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 are 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 specific symptoms such as 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.

The following links have more information on MHT. Be aware that websites from other countries may contain information that differs from New Zealand recommendations.
Menopause(external link) Sexual Wellbeing Aotearoa
Menopause health information(external link) Australasian Menopause Society
Menopause and HRT(external link)  Patient Info, UK

Medsafe Consumer Information Sheets:

Ovestin cream(external link) and pessaries(external link) 
Oestrogen tablets: Estrofem(external link) Progynova(external link) Ovestin(external link) Premarin(external link) 
Oestrogen skin patch: Estradot(external link) Climara(external link)
Oestrogen plus progestogen tablets: Trisequens(external link) Kliogest(external link) Kliovance(external link) 
Baezedoxifene plus oestrogen: Duavive(external link)
Tibolone: Livial(external link) 
Progestogens: Utrogestan(external link) Primolut N(external link) Provera(external link) Crinone(external link)

Resources

5 questions to ask about your medications(external link) Health Quality and Safety Commission, NZ, 2019 English(external link), te reo Māori(external link)

References

  1. Mehta J, Kling JM, Manson JE. Risks, benefits, and treatment modalities of menopausal hormone therapy: Current Concepts.(external link) Front. Endocrinol. 2021;12:564781
  2. Panay N, Hamoda H, Arya R, et al. The 2013 British menopause society & women’s heath concern recommendations on hormone replacement therapy(external link) Menopause Int 2013;19(2):59-68
  3. Non-hormonal treatment options for menopausal symptoms(external link) Menopause Australia 

Brochures

menopause what are the symptoms

Menopause - what are the symptoms?

Australasian Menopause Society, 2018

non hormonal treatment options for menopausal symptoms

Non-hormonal treatment options for menopausal symptoms

Australasian Menopause Society, Australia, 2018

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Credits: Sandra Ponen, Pharmacist, Healthify He Puna Waiora. Healthify is brought to you by Health Navigator Charitable Trust.

Reviewed by: Dr Phoebe Hunt, Sexual Health Registrar, Northland; Angela Lambie, Pharmacist, Auckland

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