Hormone replacement therapy

When a woman goes through menopause, the amount of oestrogen - a female sex hormone - in the body is dramatically reduced. Many women experience unpleasant symptoms as a result. Hormone replacement therapy (HRT), now more commonly known as menopausal hormone therapy (MHT), can reduce these troublesome menopause symptoms.

While MHT is effective, there are some risks associated with its use, so you need to discuss the pros and cons of treatment with your doctor. You may decide to try other treatments to help relieve menopause symptoms, either together with hormone therapy or instead of it.

What symptoms can menopausal hormone therapy (MHT) help?

Menopausal hormone therapy (MHT) is the most effective treatment available for the relief of hot flushes and night sweats. It is also effective in treating vaginal dryness.

MHT may also help with:

  • insomnia;
  • mood swings during menopause; and
  • muscle aches and pains.

Another benefit of MHT is that it helps maintain bone density and reduces the risk of fractures due to osteoporosis (a condition that makes bones weak and brittle). However, other medicines are available for the treatment and prevention of osteoporosis, and MHT is not routinely recommended for this purpose alone. (MHT may be used to prevent osteoporosis in certain women younger than 60 who are at high risk of osteoporosis and are considering taking MHT in the short term to relieve menopausal symptoms.)

What are the risks of MHT?

There are risks associated with ongoing use of MHT/HRT. The risks vary depending on:

  • the dose and type of MHT you take;
  • how you take the MHT (tablets are associated with higher risks than non-oral MHT);
  • the duration of use (how long you take it); and
  • the age you are when you start MHT.

In general, the risks are are considered to be low in most women who take MHT within 10 years of their last period.

The main risks to consider include the following.

  • Blood clots: MHT taken as tablets increases the risk of having a blood clot. The risk is further increased with increasing age and when there are other risk factors, such as obesity and smoking. The risk is lower with oestrogen-only MHT, and there is minimal risk of blood clots associated with MHT given as skin patches or gels. Overall, the risk of blood clots is low in healthy women younger than 60 years.
  • Stroke: Oral MHT may increase the risk of stroke in some women. However, the risk of stroke is very low in women younger than 60 years.
  • Heart disease: The effect of MHT on the risk of heart disease relates to the type of MHT, when MHT is started, how long you take it and whether there is any underlying heart disease. There is no evidence of an increased risk of heart disease in women who start MHT within 10 years of menopause or are younger than 60 years.
  • Breast cancer: The risk of breast cancer is slightly increased when combined MHT or tibolone is used, and the risk relates to how long you take it. Your risk decreases after you stop using MHT. Oestrogen-only MHT is associated with little or no change in breast cancer risk.
  • Gallbladder disease: MHT is associated with an increased risk of gallbladder disease. The risk may be reduced by using skin patches rather than tablets.

Overall, using MHT for up to 5 years is considered safe and effective for most women.

Should I take MHT or not?

It’s worth discussing the risks and benefits of MHT with your doctor to work out whether MHT is right for you. The more you understand, the easier it should be to make an informed decision.

In general, the benefits of MHT seem to outweigh the risks for most women younger than 60 years of age or within 10 years of the start of menopause. MHT is often recommended for women who have an early (premature) menopause.

If you do start taking MHT, your doctor will want to continue to make sure that the pros outweigh the cons in your case. Your should see your doctor at least once a year to work out whether you should continue taking it.

Remember, MHT is not a ‘quick fix’ solution for the challenges of menopause - it’s just one aspect of its overall management. It’s important to also get plenty of physical activity, eat a varied diet low in fat and high in fruits and vegetables, and make time for relaxation. Plus there are non-hormonal treatments that may help.

Types of menopausal hormone therapy

There are several different formulations and combinations of hormones available as MHT in Australia. These include oestrogen-only MHT, combined MHT, oestrogen plus bazedoxifene and tibolone. The type that will be most suitable for you will depend on several factors, including:

  • when you had your last period;
  • what symptoms you are experiencing;
  • whether you have had a hysterectomy (surgery to remove the uterus); and
  • whether you have any other medical conditions.

You may need to try different types of MHT before you find one that suits you.

Oestrogen-only MHT

Oestrogen-only MHT (also called unopposed oestrogen replacement therapy) is only prescribed for women who have had a hysterectomy (removal of the uterus). That’s because oestrogen on it’s own can increase the risk of cancer of the lining of the uterus (endometrial cancer).

A progestogen (synthetic form of the female sex hormone progesterone) needs to be added to oestrogen to protect the lining of the uterus in women with an intact uterus.

It should be noted that progestogens do not help relieve unpleasant symptoms of menopause.

Combined MHT

Combined MHT contains oestrogen plus a progestogen. It can be given in 2 forms: cyclical or continuous.

  • Cyclical (sequential) combined MHT is usually given if you have menopause symptoms but are still getting periods or have not yet had a full year without periods. It involves taking oestrogen every day and adding progestogen for 10–14 days each month. Because cyclic combined HRT mimics your normal menstrual cycle, you should have a withdrawal bleed (like a period) each month.
  • Continuous combined MHT is usually prescribed for women who have had more than a full year without periods. It involves taking oestrogen and progestogen every day, but the dose of progestogen is often lower than for cyclical combined MHT. You should not experience bleeding once treatment is established, which may take 3-6 months.

Combination MHT is available in Australia as tablets and skin patches. If you use an oestrogen-only tablet or skin patch and you have not had a hysterectomy, you’ll need to also take progestogen in some form (tablets or IUD).

Tibolone

Tibolone is an option for women who have gone through the menopause. It’s a synthetic steroid, and acts like oestrogen on some body tissues, but like progesterone and testosterone on others.

Tibolone may be less effective than combined MHT in relieving menopausal symptoms. But it may reduce the risk of osteoporosis and help improve sex drive and mood. It is not recommended for women who have had breast cancer. Tibolone may also increase the risk of stroke in women older than 60 years.

Oestrogen plus bazedoxifene

Oestrogen plus bazedoxifene (a selective oestrogen receptor modulator) is a newer treatment option for women with moderate-to-severe hot flushes. It helps prevent osteoporosis and seems to be associated with fewer adverse events than MHT that contains oestrogen plus medroxyprogesterone.

How long should I take MHT?

Doctors usually suggest taking the lowest dose of MHT for the shortest amount of time necessary to control your symptoms. However, it depends on your individual needs.

It’s usually recommended that MHT is used short-term (for 2 to 5 years) to treat menopausal symptoms, as this length of treatment is not associated with an increased risk of risks such as breast cancer. Longer term use is possible if you and your doctor believe that the benefits outweigh the risks.

You should see your doctor at least once a year to review the need to continue MHT.

How can MHT be taken?

MHT can be given in various ways, including as tablets, skin patches and vaginal creams.

Types of menopausal hormone therapy (MHT) available in Australia
Method of taking MHTHormones includedBrand namesAdditional information
Tablets
Tablets are still the most popular and widely available method of MHT. Most tablets come in easy-to-follow calendar packs.
Oestrogen and progestogen (combination)Cyclical: Femoston, Trisequens
Continuous: Angeliq 1/2, Femoston-Conti, Kliovance, Kliogest
Easy to take but associated with an increased risk of side effects and risks compared with other types of MHT.
OestrogenEstrofem, Ovestin, Premarin, Progynova, ZumenonCan be used alone (without progestogen) in women who have had a hysterectomy.
Synthetic progestogen tabletsPrimolut N, Provera, RaloveraTo be used with oestrogen therapy, usually in the last 14 days of the cycle in women who have not had a hysterectomy.
Micronised progesteronePrometrium CapsulesTo be used with oestrogen therapy in women who have not had a hysterectomy. May be associated with a lower risk of breast cancer and heart disease than synthetic progestogens.
TiboloneLivial, XyvionAn alternative to traditional MHT in women who have not had a period for at least a year.
Oestrogen plus bazedoxifeneDuaviveCan be used to treat severe hot flushes. May have fewer side effects compared with certain types of MHT that contain progestogen.
Skin patches
Skin patches are applied to your skin and release the hormones into your body slowly over time. The patches come in varying strengths, and usually need to be replaced once or twice a week depending on the product.
Oestrogen plus progestogen (combination)Cyclical: Estalis Sequi
Continuous: Estalis Continuous
May have fewer risks and side effects than tablets because the dose of oestrogen is lower, but some women may find them irritating to the skin.
May be a good choice for women who find they experience side effects such as nausea from oestrogen tablets and those who frequently forget to take tablets.
OestrogenEstraderm MX, Estradot and Climara
Skin gelOestrogenSandrenaHelpful for women who cannot tolerate tablets and who do not want to wear a patch.
Gel is rubbed onto the skin once daily.
Vaginal creams or pessaries (tablets that dissolve when placed in the vagina)OestrogenCream: Ovestin
Pessaries: Ovestin Ovula, Vagifem Low
Works better for relieving symptoms such as vaginal dryness or bladder problems, and associated with fewer risks than other forms of MHT.
Hormone-releasing intrauterine device (IUD)ProgestogenMirenaUsed in combination with oestrogen tablets or patches in women with an intact uterus.
Mirena often results in lighter periods, or no periods at all in many women, so may be a good option for women having heavy periods leading up to menopause.

MHT and contraception

While it is unlikely that you will get pregnant if you are in the process of going through menopause, it should be noted that MHT is not a type of contraception and will not stop you from getting pregnant.

If you are still having periods, even if they are not regular, you should discuss with your doctor whether or not you still need to use contraception. A non-hormonal type of contraception is usually recommended.

Before starting MHT

Before prescribing MHT, your doctor will suggest a gynaecological examination and blood pressure check. Your doctor may also suggest an HPV cervical cancer screening test (these have replaced Pap smear tests) and a mammogram.

A bone density scan may also be recommended if you are considered at particular risk of developing osteoporosis.

What are the side effects of MHT?

Some women experience side effects as a result of taking MHT. These may include:

  • breast enlargement and tenderness;
  • abdominal bloating and fluid retention;
  • mood changes;
  • nausea; and
  • headaches.

These side effects usually get better with time. If not, your doctor may recommend a change in the dose or type of MHT.

Irregular vaginal bleeding - breakthrough bleeding - is a common side effect in the first 3 to 6 months of taking MHT. If you have persistent or unusual bleeding, you should see your doctor.

Does MHT cause weight gain?

MHT should not cause weight gain in the long term.

Who should not take MHT?

You may not be able to take MHT if you have, or have had, the following:

  • breast cancer;
  • endometrial cancer;
  • unexplained vaginal bleeding;
  • liver disease;
  • a history of blood clots;
  • coronary heart disease (angina, history of heart attack); or
  • severe chronic kidney disease.

There are also some conditions that need to be monitored more closely when MHT is taken.Your doctor can give you specific advice about whether MHT will be suitable for you and check-ups that are needed while you take it.

What are bioidentical hormones?

Bioidentical hormones are defined as ‘compounds that have exactly the same chemical and molecular structure as hormones that are produced in the human body’.

Bioidentical hormones are made by compounding chemists, often in the form of lozenges or ‘troches’ that are dissolved in the mouth or as creams. They are composed of a mix of hormones, such as different types of oestrogens, progestogens and sometimes testosterone.

Bioidentical hormones are often touted as being more ‘natural’ than MHT, but in fact all hormone preparations are synthesised. In addition, there is no scientific data to support the safety or effectiveness of bioidentical hormones in relieving menopause symptoms, and there is insufficient evidence showing that these products are free of contaminants. Their use is not supported by the Australasian Menopause Society.

Are there complementary treatments for menopause?

While there is an increasing range of alternative treatments for menopause symptoms, so far there is little good evidence that they are effective. Herbal medicines can have adverse effects and can also interact with other medicines.

Talk to your doctor about any alternative, herbal or other complementary treatments for relieving troublesome symptoms of menopause.

References

1. Australasian Menopause Society. What is menopausal hormone therapy (MHT) and is it safe? (updated Jan 2018). https://www.menopause.org.au/health-info/fact-sheets/what-is-menopausal-hormone-therapy-mht-and-is-it-safe (accessed Jun 2018).
2. Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Menopausal hormone therapy advice; July 2015. https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical%20-%20Gynaecology/Menopausal-Hormone-Therapy-Advice-(C-Gyn-16)-Re-write-July-2015.pdf?ext=.pdf (accessed Jun 2018).
3. Australasian Menopause Society. Combined menopausal hormone therapy (MHT) (Apr 2016). https://www.menopause.org.au/images/stories/infosheets/docs/AMS_Menopause_Combined_MHT.pdf (accessed Jun 2018).
4. Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Management of the menopause (November 2014). https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical%20-%20Gynaecology/Management-of-the-Menopause-(C-Gyn-9)-Review-November-2014.pdf?ext=.pdf (accessed Jun 2018).
5. BMJ Best Practice. Menopause: should I take HRT? Patient information from BMJ (published 1 Mar 2018). https://bestpractice.bmj.com/info/ (accessed Jun 2018).
6. Australasian Menopause Society. Bioidentical hormones for menopausal symptoms (updated Jan 2017). https://www.menopause.org.au/hp/information-sheets/212-bioidentical-hormones-for-menopausal-symptoms (accessed Jul 2018).
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