Menopausal Hormone Therapy (MHT)

Menopause is the permanent cessation of menstruation. It can occur as early as age 40 or as late as nearly age 60s. The average age of menopause is usually about 49 to 51. It is normally diagnosed in females after 1 year of absent menstrual flow. Menopause does not occur suddenly. It is a slow transition and peri-menopause usually begins a few years before the last menstrual period. Menopause is only one event in the transition period involving changes in the female body between the mid or late 40’s, when the production of female hormones (estrogen and progesterone) begins to decline. Most of the signs and symptoms of menopause arise from this decrease in estrogen production. Therefore, MHT (referring to both the EPT and ET) is often given to women who have significant symptoms that have an impact on their daily activities.

Benefits

It is the most effective pharmacological treatment for menopause symptoms and it has been shown to prevent the bone loss associated with osteoporosis and reduce the risk of fractures. In many women, there is also an improvement in the quality of life, with an overall reduction in all-cause mortality in women less than 60-year-olds.

Risks

The use of MHT is thought to increase the risk of breast cancer, blood clots, cardiovascular diseases and stroke. Fortunately, the actual incidence due to it is still extremely low. Hormones that contain oestrogen and progestogen (estrogen-progestogen therapy or EPT) may increase breast cancer risk especially if taken for 5 years or more. The risk will fall again once you stop taking EPT. However, for estrogen therapy alone (ET), the risks seem to be much lower. For further reading on breast cancer risk, click HERE.

If HRT is started before age 60 in a healthy individual, it is not likely to increase the risk of cardiovascular disease or stroke. HRT and ovarian cancer risk is still unclear but even if there is an association, the net risk effect is still very low.

You should not take MHT if you:

  • Have breast cancer or other hormone-dependent cancer.
  • Have undiagnosed abnormal genital bleeding.
  • Have coronary heart disease, previous blood clots,s or stroke and women at high risk for these conditions.
  • Are pregnant.
  • Have had a previous reaction or allergic response to estrogen.

Possible side-effects or adverse reactions:

The most common undesirable side effect is abnormal uterine bleeding, which usually diminishes over time. Persistent bleeding or abnormal ultrasound scan finding of the uterus inner lining will warrant further investigation. Other possible side effects are:

  • Swollen feet or legs; bloating; weight gain, pre-menstrual (PMS) like symptoms.
  • Breast tenderness or pain.
  • Pelvic cramping; nausea; vomiting.
  • Fatigue; depression; headaches; mood changes.
  • Symptoms of a blood clot – this is uncommon and may present as sudden or severe headache, sudden loss of coordination, sudden loss or change in vision, sudden slurring of speech, weakness or numbness in arm or leg, chest discomfort or pain, sudden unexplained shortness of breath, groin or leg pain or swelling (especially the calf).

Medications

There are two types of MHT:
A. Estrogen-progestogen therapy (EPT) consists of a combination of estrogen with a progestogen, which is another type of hormone. EPT is usually prescribed for women who have a uterus. The addition of progestogen helps to protect the uterus from developing uterine cancer due to the estrogen effect. The progestogen may be taken every day (continuous combined EPT) or for 12-14 days of each monthly treatment cycle (sequential combined EPT).

  1. Sequential combined EPT is given to women who are peri-menopausal and still having menstrual bleeding (which may be irregular). Women on this combination type will continue to have periods unless they change to the continuous type later in life.
  2. Continuous combined EPT is usually given to women who are already menopause (meaning more than 1 year without menses). This is the “period free” type of EPT whereby you are not expected to have any menses or bleeding.

B. Estrogen therapy (ET) contains only estrogen. This is given to women without a uterus (following a hysterectomy which is the surgical removal of the womb), With the absent uterus, the progestogen hormone pills are no longer necessary.

Many concerns were raised about the side effects of MHT, particularly the increased breast cancer and blood clot risks. The increased risk is minimal and MHT remains the most effective way to relieve menopause symptoms and prevention of osteoporosis. It is important to note that many women face difficulties in going through the menopause transition. They often suffer in silence, thus affecting their quality of life. There is often a reluctance in these women to start MHT due to concern and misconception especially with regards to the breast cancer risks.

If women start MHT around the time of menopause the risk is exceedingly small if it is started for the right reasons namely, to treat symptoms and improve the quality of life. It should not be given solely for the prevention of the effects of aging. MHT is probably not appropriate to be started for those above the age of 60 when the risks far outweigh the benefits. For some women, long-term use of MHT may be necessary for continued symptom relief and improved quality of life.

In prescribing hormones, the severity of menopause symptoms, risk factors and other medical conditions should be taken into consideration when weighing the risks and benefits of MHT. The decision to use hormone therapy after menopause should be made by a woman and her doctor after weighing all the above. This will affect the dose, forms, and regimen for each woman. For some women, the benefits of short-term use of MHT far outweigh the risks. Women who are taking any form of MHT should see their doctor regularly for health screening (including cervical and breast cancer screening), monitor side effects and discuss the continuation of the treatment.
The lowest dose hormone is usually given that can offer relief of symptoms. If a scheduled dose is missed, take it as soon as possible. If the timing is near to the next dose, you should skip the missed one. Taking it too close to each dose will double up the oral dose and should be avoided if possible. If nausea is a problem, take the tablets with food or immediately after a meal. Nausea will usually disappear over time.

Vaginal estrogen cream is available that can be prescribed to relieve vaginal and urinary symptoms. Besides MHT, alternative therapies may include dietary and lifestyle changes, vitamin supplements and herbs. There are many over-the-counter herbal remedies for the treatment of menopausal symptoms. Compounded bioidentical products are also available and these refer to hormones that are similar to the natural ones produced by the ovaries. However, many of these products are not regulated by the regulatory authorities with regards to the quality and the safety profiles. Therefore, one should be extremely careful when considering these types of options because some of these products may contain hormones or chemicals in unknown quantities. Some of these may be harmful or in an inappropriate dosage. Please discuss this with your doctor for further advice.

You should see your doctor immediately if you have:

New or/and unexplained symptoms develop. Drugs used in treatment may produce side effects and you should discuss these with your doctor. Many mild symptoms will disappear over the next few cycles.

To print a pdf copy, click HERE

Reference and further reading:

Hormone replacement therapy (HRT): further information on the known increased risk of breast cancer with HRT and its persistence after stopping (article from the www.gov.uk website) – click HERE for the link