Understanding Menopausal Hormone Therapy - what every woman should know.
Introduction
Menopausal hormone therapy (MHT)—sometimes called hormone replacement therapy (HRT)—has been the subject of intense research, debate, and evolving understanding over the past two decades. If you're navigating menopause and considering MHT, you've likely encountered conflicting information that leaves you confused about whether it's right for you.
This article aims to cut through the confusion by presenting what the current evidence actually tells us about MHT: what it is, who it helps, what the benefits are, what risks exist, and how to make an informed decision that's right for your unique situation.
The most important takeaway? MHT is not a one-size-fits-all treatment. The type, dose, route of administration, and duration matter significantly—and so do your individual health profile, age, and time since menopause.
What Is Menopausal Hormone Therapy?
MHT is a treatment that uses hormones—primarily estrogen, often combined with a progestogen (synthetic progesterone) or progesterone itself—to alleviate symptoms associated with menopause. The primary goal is symptom relief, though it can offer additional health benefits for some women.
The Basic Components
Estrogen is the main hormone used in MHT and is responsible for most of its benefits. Today, most women use estradiol (identical to what your body produced before menopause) rather than older formulations like conjugated equine estrogens (CEE).
(Fun Fact: Premarin was originally made from the urine of pregnant mares, starting production in 1941. The name was derived from PREgnant MARes urINe! )
Progestogen or progesterone is added for women who still have a uterus to protect the lining (endometrium) from overgrowth that estrogen alone can cause.
If a woman with a uterus takes oestrogen alone, this overgrowth can cause endometrial cancer – cancer of the lining of the womb. Women who've had a hysterectomy can use estrogen alone, because they have no womb with womb lining.
Different Forms of MHT
MHT comes in various forms, and this matters more than you might think:
Oral tablets: Taken by mouth daily
Transdermal preparations: Patches or gels/creams applied to the skin
Vaginal preparations: Low-dose local estrogen cream or pessaries for genitourinary symptoms only
The route of administration significantly affects both effectiveness and safety. Transdermal estrogen (through the skin) bypasses the liver and has a different—often more favorable—safety profile than oral estrogen, particularly regarding blood clot and stroke risk.
Types of Regimens
Sequential MHT provides continuous estrogen with progestogen added for part of each month (typically 12-14 days). This is often used during perimenopause and usually results in a scheduled withdrawal bleed. It links in with and supports your natural cycle which is still occurring.
Continuous combined MHT provides both estrogen and progestogen daily without breaks. This is typically used after menopause (one year after the final period) and aims to eliminate bleeding, though breakthrough bleeding is common in the first 3-6 months.
Estrogen-only MHT is used by women without a uterus and generally has the most favorable risk profile.
What Are the Evidence-Based Benefits of MHT?
Relief of Menopause Symptoms: The Primary Benefit
MHT is considered the most effective currently available treatment for symptoms linked to menopause. These include:
Vasomotor symptoms (hot flashes and night sweats): These affect most women during menopause, with 25% experiencing severe symptoms. MHT dramatically reduces both the frequency and severity of hot flashes.
Sleep disruption: Often related to night sweats but also directly affected by hormonal changes
Genitourinary symptoms: Vaginal dryness, discomfort during intercourse, urinary urgency, and recurrent urinary tract infections
Mood changes and fatigue: While not exclusively caused by menopause, many women experience significant improvement in mood and energy with MHT
For women whose quality of life is significantly impacted by these symptoms, MHT can be genuinely life-changing.
Bone Health: A Significant Long-Term Benefit
One of the most robust findings in MHT research is its protective effect on bones. Studies show that MHT reduces the risk of hip, vertebral, and other fractures by 20-37%. This protection is most pronounced when MHT is started before age 60.
Importantly, while bone protection diminishes somewhat after stopping MHT, there's no "rebound" increase in fracture risk. For women with early menopause, osteopenia, or osteoporosis, MHT should be considered as a first-line option for bone protection.
Cardiovascular Health: It's Complicated (and Timing Matters)
This is where the story gets nuanced. Early observational studies suggested MHT protected against heart disease. However, large randomized trials—particularly the Women's Health Initiative (WHI) study—showed increased cardiovascular risks in older women or those many years past menopause.
The current understanding centers on what's called the "timing hypothesis" or "window of opportunity":
For healthy women under 60 or within 10 years of menopause: MHT appears to have neutral to potentially beneficial effects on cardiovascular health. In the WHI study, women aged 50-59 on estrogen-only therapy had a small but statistically significant reduction in cardiovascular disease risk.
For older women or those with established vascular disease: MHT may increase cardiovascular risks and is not recommended for disease prevention.
The key message: if you're going to use MHT, starting it earlier in menopause appears safer for your heart than starting it decades later.
Other Potential Benefits
Some women report improvements in:
Cognitive function and concentration
Mood and motivation
Muscle strength
Skin quality
However, evidence for these benefits is less robust than for symptom relief and bone health.
What Are the Risks of MHT?
Understanding MHT risks requires acknowledging that not all MHT is created equal. Risks vary significantly based on:
Type of estrogen and progestogen used
Route of administration (oral vs. transdermal)
Dose
Duration of use
Your age when starting
Your individual health profile
Blood Clot Risk (Venous Thromboembolism or VTE):
· Oral estrogen increases VTE risk by 2-4 fold compared to non-users. This is because oral estrogen passes through the liver, activating the blood clotting system.
· Transdermal estrogen (patches, gels, sprays) does NOT appear to increase VTE risk when used at standard doses with recommended progestogens like micronized progesterone or a levonorgestrel-releasing intrauterine system (IUS).
· This is one of the most important distinctions in MHT safety and is why transdermal preparations are now preferred, especially for women at higher baseline VTE risk.
Progesterone does not increase clot risk or stroke risk, because it does not affect the blood clotting system.
Stroke Risk:
· Oral estrogen slightly increases stroke risk.
· Transdermal estrogen at doses equivalent to a 50 μg/day patch or lower does not appear to increase stroke risk above a woman's baseline. Higher doses may carry increased risk.
· Again, transdermal preparations are preferred for women with stroke risk factors.
Breast Cancer Risk:
· This is often women's greatest concern, and understandably so. Here's what the evidence shows:
· The overall increased risk during early post-menopause for 5 years of therapy appears small in otherwise healthy women. However, risk increases with each additional five years of use.
Type of MHT matters significantly:
Estrogen-only therapy has the lowest breast cancer risk—and some studies of CEE (conjugated equine estrogen) show no increased risk or even a decreased risk
Estrogen plus progestogen increases risk more than estrogen alone
Micronized progesterone (Utrogestan) and dydrogesterone appear to confer lower risks than older synthetic progestogens when used at recommended doses
Body weight matters: Interestingly, MHT has the least impact on breast cancer risk in women with overweight or obesity and the greatest impact in normal-weight women.
Important context: Many lifestyle factors—including obesity, high alcohol intake, and lack of exercise—independently increase breast cancer risk. For perspective, being overweight or drinking more than one alcoholic drink daily increases breast cancer risk to a similar or greater degree than using MHT.
Vaginal estrogen (low-dose, local therapy) does NOT increase breast cancer risk.
Endometrial Cancer Risk
This risk is primarily relevant for women with a uterus. Estrogen alone increases endometrial cancer risk, which is why progestogen or progesterone must be added for endometrial protection.
Adequate progestogen dosing is critical. Recent data suggest that in some women—particularly those with obesity, diabetes, or using higher estrogen doses—standard doses of progesterone may not provide adequate protection. This has led to increased attention to unscheduled bleeding on MHT, which always requires investigation.
What About Dementia?
Current pooled data shows no clear effect of MHT on dementia risk—neither beneficial nor harmful overall. The populations and MHT types studied have been too varied to draw firm conclusions.
Who Should Consider MHT?
MHT may be appropriate for you if:
You're experiencing bothersome menopause symptoms that affect your quality of life
You're under 60 years old or within 10 years of your final period
You don't have contraindications (see below)
You understand the potential risks and benefits specific to your situation
MHT is particularly worth considering if you have:
Early menopause (before age 40) or premature ovarian insufficiency
Significant bone loss or fracture risk
Severe symptoms that haven't responded to non-hormonal approaches
Who Should Avoid or Be Cautious With MHT?
MHT is generally not recommended or requires very careful consideration if you have:
Current or previous breast cancer (though exceptions exist with careful individualized assessment)
Active or recent blood clots
Active liver disease
Unexplained vaginal bleeding
Established cardiovascular disease
History of stroke
Special considerations for women with chronic conditions: Many women with conditions like diabetes, obesity, high blood pressure, or migraine can still safely use MHT—but the type and route matter greatly. Transdermal estrogen with micronized progesterone or a progestogen-releasing IUS is generally preferred for women with these conditions. However, honest conversations about uncertainties are important, as women with multiple chronic conditions have been underrepresented in MHT research.
Making Your Decision: The Importance of Individualized Care
Perhaps the most important evolution in our understanding of MHT is recognizing that there is no universally optimal regimen. What's right for you depends on:
Your specific symptoms and how much they affect your life
Your age and time since menopause
Your personal and family health history
Your risk factors for various conditions
Your preferences and values
Questions to Discuss With Your Healthcare Provider
Based on my age, health history, and symptoms, what are my potential benefits from MHT?
What are my specific risks, and how do they compare to my baseline risk?
Which type of MHT would be most appropriate for me, and why?
If I have risk factors, are there MHT formulations (like transdermal estrogen and micronized progesterone) that might be safer for me?
How long might I need to use MHT?
What are non-hormonal alternatives if MHT isn't suitable?
How will we monitor my response and adjust treatment if needed?
What lifestyle changes could reduce my risks or improve my response to treatment?
The Shared Decision-Making Process
Modern MHT care emphasizes shared decision-making—a collaborative process where your healthcare provider shares evidence-based information, you share your preferences and concerns, and together you arrive at a treatment plan tailored to you.
This means:
You should receive clear, balanced information about both benefits and risks
Your provider should acknowledge uncertainties where data is limited
Your values and quality of life considerations should be central to the decision
The plan should be reviewed regularly, as your needs and risks may change over time
How Long Can You Use MHT?
There is no arbitrary time limit for MHT use. The guiding principle is that MHT may be continued as long as benefits outweigh risks for your individual situation.
Many women use MHT for symptom relief for several years around the menopause transition and then taper off. Others may continue longer, particularly if they're using it for bone protection or if symptoms return when they attempt to stop.
Regular review (typically yearly) with your healthcare provider is important to:
Assess whether MHT is still needed and beneficial
Evaluate any changes in your risk profile
Adjust dose or formulation as needed
Consider whether it's appropriate to continue, taper, or stop
Beyond Pills and Patches: Other Hormone Options
Vaginal Estrogen
Low-dose vaginal estrogen (Ovestin cream or pessaries) is highly effective for genitourinary symptoms and has an excellent safety profile. Importantly:
It doesn't increase breast cancer risk
It doesn't require addition of a progestogen
It can be used alongside systemic MHT or on its own
It's generally considered safe for many breast cancer survivors
Testosterone Therapy
Some women experience persistent low libido, fatigue, and reduced motivation (HSDD, or hypoactive sexual desire dysfunction) even when adequately treated with estrogen. Testosterone therapy can be considered in these cases and has been shown to improve sexual desire, arousal, pleasure, and overall wellbeing. However:
AndroFeme (testosterone cream) is the only currently registered product for postmenopausal women in NZ. It is applied once daily.
It should only be considered after other causes of symptoms are addressed
It requires monitoring and blood level testing.
Long-term safety data are limited
More research is needed on its effects in women with breast cancer risk
Tibolone
This synthetic compound has estrogenic, progestogenic, and androgenic effects. It relieves menopause symptoms and protects bone with a single daily tablet. Some studies suggest lower breast cancer risk compared to standard combined MHT, though data are limited. It is not a currently funded treatment in NZ, but is available as a self-funded option with a prescription from a doctor.
What If MHT Isn't Right for You?
For women who can't or don't wish to use MHT, alternatives exist:
For vasomotor symptoms:
Newer non-hormonal medications (like fezolinetant) show promising results
Some antidepressants (SSRIs/SNRIs) can reduce hot flashes
Cognitive behavioral therapy designed for menopause
Mind-body practices and lifestyle modifications
For bone health:
Weight-bearing exercise and resistance training
Adequate calcium and vitamin D
Bone-specific medications if needed
For genitourinary symptoms:
Vaginal moisturizers and lubricants
Low-dose vaginal estrogen (often still suitable even when systemic MHT isn't)
Vaginal DHEA
Lifestyle measures
Lifestyle approaches that benefit everyone:
Regular physical activity
Healthy diet rich in calcium and vitamin D
Maintaining healthy weight
Not smoking
Limiting alcohol
Stress management
Good sleep hygiene
The Bottom Line
Menopausal hormone therapy is a valuable treatment option that can significantly improve quality of life for many women experiencing bothersome menopause symptoms. Modern formulations—particularly transdermal estrogen combined with micronized progesterone or progestogen-releasing IUS—have more favorable risk profiles than older preparations used in early studies.
The key messages to remember:
MHT is highly effective for menopause symptoms and offers bone protection
Not all MHT is the same—type, route, and dose matter significantly for both efficacy and safety
Timing matters—starting MHT earlier (under 60 or within 10 years of menopause) appears safer than starting later
Transdermal estrogen has advantages over oral estrogen for many women, particularly regarding blood clot and stroke risk
Individual risk assessment is crucial—what's right for your friend may not be right for you
Lifestyle factors also significantly impact your overall health and menopause experience
Shared decision-making with a knowledgeable healthcare provider is essential
Menopause is a natural transition, not a disease. However, the symptoms can significantly impact quality of life, and you shouldn't have to suffer unnecessarily. Armed with accurate information and supported by a healthcare provider who takes your concerns seriously, you can make an informed decision about whether MHT is right for you.
Remember: advocating for your health includes seeking care from providers who stay current with menopause medicine and are willing to have nuanced, individualized conversations about your options.
Additional Resources
Australasian Menopause Society Fact Sheets:
https://menopause.org.au/health-info/fact-sheets
Healthify:
https://healthify.nz/medicines-a-z/m/menopausal
