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A  Guide to Menopause Hormone Therapy (MHT)

Introduction: Understanding Your Options

Welcome to your introductory guide to Menopause Hormone Therapy (MHT). In simple terms, MHT is a treatment used to replace the hormones that naturally decline during the menopausal transition. The symptoms of this transition can significantly impact a person's quality of life, and MHT is the most effective treatment available for managing them.

The purpose of this guide is to clearly explain the different types of MHT, the hormones involved, and how they are used. By understanding these fundamentals, you can feel more empowered to have informed and productive conversations with your healthcare provider about your personal health journey.

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1.0 The Core Components: What Hormones Are in MHT?

Menopause Hormone Therapy primarily utilizes versions of two key hormones to achieve its effects: oestrogen (spelt oestrogen in America)  and progestogen. Each plays a distinct and critical role in the treatment plan.

1.1 The Role of Oestrogen

Oestrogen is the main hormone used in MHT because it is responsible for relieving the most common and often distressing symptoms of menopause. Its use has been proven highly effective for treating:

• Vasomotor Symptoms: These are the most well-known symptoms, including hot flashes and night sweats. Oestrogen replacement is the most effective therapy for providing relief.
• Genitourinary Syndrome of Menopause (GSM): This includes a range of symptoms affecting the urinary and genital areas, such as vaginal dryness, burning, irritation, lack of lubrication, painful intercourse, urinary urgency, and recurrent urinary tract infections.
• Bone Loss: Oestrogen deficiency accelerates bone loss after menopause. MHT is effective at preserving bone mineral density and helps to prevent osteoporosis. While MHT is not typically recommended for the sole purpose of osteoporosis prevention in women over 60, it is a key benefit for those taking it for symptom relief.

For these reasons, oestrogen is considered the "workhorse" of MHT, directly addressing the most disruptive symptoms of menopause.

1.2 The Role of Progestogen

Progestogen, a category that includes both natural micronized progesterone and synthetic progestins, is added to MHT for one crucial safety reason. Its primary purpose is to protect the uterine lining (endometrium).

Oestrogen, when taken alone (unopposed), stimulates the growth of cells in the endometrium(lining of uterus) . This can lead to a condition called endometrial hyperplasia and significantly increase the risk of endometrial cancer. Progestogen counteracts this effect. Therefore, progestogen is only required for individuals who still have their uterus.

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Now that we understand the roles of oestrogen and progestogen, let's look at how they are combined into different treatment plans.

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2.0 Common MHT Regimens: How the Hormones Are Combined

The specific combination and schedule of hormones in an MHT plan depend almost entirely on one key factor: whether the individual has a uterus.

2.1 For Individuals Without a Uterus: Oestrogen-Only Therapy (ET)

If a person has had a hysterectomy (surgical removal of the uterus), they do not need progestogen for endometrial protection. In this case, the treatment plan is straightforward: they typically only need to take oestrogen. This is known as Oestrogen-Only Therapy, or ET.

2.2 For Individuals with a Uterus: Combined Oestrogen and Progestogen Therapy (EPT)

For individuals who still have their uterus, it is essential to take a progestogen alongside oestrogen for safety. This is called combined oestrogen and Progestogen Therapy, or EPT. There are two main ways this combination is scheduled.

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Beyond the hormone combination, the way MHT is delivered into your body is another key part of personalizing treatment.

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3.0 Delivery Methods: From Pills to Patches

MHT can be administered in two main ways: systemically, where the hormones travel through the bloodstream to affect the whole body, or locally, where the treatment is applied to target a specific area.

3.1 Systemic vs. Local Therapy

Understanding the difference between these two approaches is key to understanding their use.

• Systemic Therapy: This method is used to treat whole-body symptoms. It is the correct choice for managing hot flashes, night sweats, and for protecting against bone loss. Systemic hormones are delivered via:
• Oral pills
• Transdermal patches, gels, and sprays
• Local Therapy: This method is used only for treating the symptoms of Genitourinary Syndrome of Menopause (GSM), such as vaginal dryness, irritation, or urinary symptoms. The goal is to treat the affected tissues directly with very low doses of oestrogen. Local hormones are delivered via:
• Vaginal creams, tablets, rings, and suppositories

An Important Safety Note: Because the dose is so low and absorption into the bloodstream is minimal with local vaginal therapies, progestogen is not required for endometrial protection.

3.2 A Closer Look at Systemic Options: Oral vs. Transdermal

For systemic therapy, the choice between taking a pill (oral) and using a skin patch, gel, or spray (transdermal) is one of the most important decisions, as it has significant safety implications.

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With so many combinations and delivery methods, treatment is carefully tailored to each person's needs.

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4.0 Finding the Right Fit: Dosing and Personalization

The guiding principle of MHT is to use the lowest effective dose that successfully relieves symptoms and achieves the patient's goals. Treatment is not one-size-fits-all; it is highly individualized. Healthcare providers consider several factors when creating a personalized treatment plan:

• Symptom type and severity: Is the primary concern hot flashes, bone health, or GSM?
• The patient's personal preference: Do they prefer a daily pill, a patch that is changed twice weekly, or a daily gel?
• Whether the patient has a uterus: This determines if progestogen is needed.
• The patient's age and time since menopause: Risks and benefits can change depending on when therapy is started.
• Personal and family medical history: Other health conditions (comorbidities) and risk factors are crucial for determining the safest options.

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Finally, let's clarify a few common terms and discuss another hormone that sometimes plays a role in treatment.

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5.0 Important Distinctions and Additional Hormones

5.1 "Body-Identical" vs. Unregulated "Compounded" MHT

You may hear different terms used to describe hormones, and it is vital to understand the distinction for your safety.

• Regulated "Body-Identical" Hormones: These are hormones, like estradiol and body-identical micronized progesterone (or biologically similar progestogens like dydrogesterone), that are manufactured by pharmaceutical companies and are structurally identical to the ones produced naturally in the human body. They are approved by regulatory agencies like the FDA, which means they have been rigorously tested for safety, efficacy, purity, and consistent dosing.
• Unregulated "Compounded Bioidentical Hormones": These are custom-mixed hormone preparations made by specialized pharmacies. Major medical groups, including The Menopause Society and the American College of Obstetricians and Gynaecologists (ACOG), explicitly do not recommend their use. The primary concerns include a lack of regulation, minimal safety and efficacy data, and variability in purity and potency, which can lead to under- or overdosing.

5.2 The Role of Testosterone

Testosterone is another important hormone that declines with age in women. While it is sometimes promoted for a variety of symptoms, its primary and evidence-based role in menopause management is for treating a specific condition:

• Hypoactive Sexual Desire Disorder (HSDD): This is characterized by a distressing low libido that is not explained by other factors and has not been resolved by adequate oestrogen therapy. For these individuals, adding testosterone can significantly improve sexual desire.

Current evidence has not established a clear benefit for using testosterone to treat other symptoms like changes in mood or cognition.

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6.0 Your MHT Journey: A Personal Decision

While historical studies once caused confusion and concern, modern MHT offers a wide range of well-researched and personalized options for improving health and well-being during the menopausal transition. The decision to start, continue, or stop MHT is a personal one, with the ultimate goal being to improve your quality of life.

The most critical step is engaging in shared decision-making with a knowledgeable healthcare provider. Together, you can weigh your individual benefits and risks, discuss your preferences, and find the personalized treatment plan that is the right fit for you.

Other sources of Information

Australian Menopause Society

Patient Info, UK