Everything You Need to Know About Menopause Hormone Therapy (Including Why We're Not Calling It HRT)
Nothing is better than menopause hormone therapy (MHT) when it comes to relieving hot flashes, vaginal dryness, urinary issues, and other symptoms of menopause, says Dr. Mary Jane Minkin, a clinical professor at Yale School of Medicine and a practicing gynecologist with a special interest in menopause. Not only can treatment help you alleviate symptoms, it may also offer long-term health benefits, like protecting against bone loss and cardiovascular disease and decreasing your risk of Alzheimer’s disease. Here’s what you need to know.
What is menopause hormone therapy or MHT — and is it different from Hormone Replacement Therapy or HRT?
Menopause hormone therapy (MHT) replenishes declining hormone levels — primarily estrogen — to treat multiple symptoms at once. While menopause hormone therapy is a newer term, it refers to the same treatment traditionally referred to as Hormone Replacement Therapy (HRT). Many doctors use the term MHT or even just “Hormone Therapy” (HT) to distinguish it from the hormone replacement that can be prescribed for women at younger ages to treat conditions other than menopause, such as premature ovarian insufficiency. However, all of these terms refer to the use of prescription hormones to alleviate symptoms of menopause.
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“Many patients may begin to find relief of hot flashes as early as two weeks, with improvement in sleep and mood,” explains Dr. JoAnn Pinkerton, a professor of ob-gyn and director of the Midlife Health Center at the University of Virginia and executive director emeritus of the Menopause Society. “But the maximum benefit is usually by six to eight weeks.”
What are the most common types of menopause hormone therapy?
There are two main ways to restore estrogen: systemic estrogen therapy and local estrogen therapy. There are pros and cons to each. Your provider can help you figure out which one is right for you based on your age, preference, medical history, and whether you’ve had a hysterectomy.
Systemic estrogen therapy
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How it works: Estrogen is released into the bloodstream and travels to the organs and tissues where it’s needed.
What it can treat: A range of common menopause symptoms, including hot flashes, night sweats, and vaginal dryness. It can also protect against bone loss.
Common forms
Pill
Skin patch
Cream
Gel
Spray
Vaginal ring
Local estrogen therapy
How it works: Treatment is applied directly to the vagina and low doses of estrogen are absorbed by the vaginal tissues
What it can treat: Vaginal dryness, pain during sex, urinary issues
Common forms:
Cream
Tablet
Gel
Vaginal ring
Depending on your individual health profile, you may also be prescribed other hormones together with estrogen. These can include:
Progesterone (called “combination therapy” when used with estrogen)
How it works: Progesterone is released into the bloodstream and travels to the organs and tissues where it’s needed. Prescribed for women with a uterus.
What it does: Protects the lining of the uterus and lowers the risk of uterine cancer.
Common forms: It can be combined with estrogen in a pill or patch or taken separately.
Pill
Skin patch
Intrauterine device (IUD)
Testosterone
How it works: Treatment is applied directly to the skin and low doses of testosterone are absorbed into the bloodstream.
What it does: Though not FDA-approved for women, testosterone can help improve low sex drive.
Common forms:
Cream
Gel
Keep in mind that providers have no shortage of tools in their toolbox when it comes to helping you find relief from symptoms. For instance, if you’re struggling to get a full night’s sleep, you might be prescribed an estrogen patch and progesterone pill at bedtime. Or if your hot flashes are unbearable, your provider might tinker with your dosage.
Each type of treatment and combination has pros and cons, so talk to your provider about what’s right for you. In general, they’ll prescribe the lowest dose you need.
What are the pros and cons of bioidentical hormones?
Made from plant sources, bioidentical hormones are similar — though not identical — to the natural hormones our bodies produce. Some bioidenticals, like oral progesterone and estradiol, are approved by the FDA and available with a prescription.
Others are compounded drugs made by a compounding pharmacist using a doctor’s prescription. These customized hormones are not regulated by the FDA, and according to the American College of Obstetrics and Gynecologists, pose more risk because they “vary in strength and purity.”
They also can be much more expensive and there’s no evidence to back up the claims that biodenticals are safer or more effective than their synthetic counterparts. Bottom line: Talk to your provider before trying biodenticals.
Are there risks to using hormone therapy?
There’s been a lot of misinformation and confusion about the risks of menopause hormone therapy which has been used safely for decades. While there are risks to using any medication, the benefits in improving your quality of life and providing relief for debilitating symptoms often outweigh the risks. Talk to your provider about your individual situation to make the choice that’s right for you.
Recent studies have revealed that while there are added risks to using MHT, they vary based on a woman’s age, health history, and the dose and type of hormone therapy she’s using.
Here are a few examples:
The benefits outweigh the risks if MHT begins before a woman turns 60 or is within 10 years of menopause. Women who start MHT at age 60 or older — or are more than 10 years from the start of menopause — are at greater risk of breast cancer, heart disease, stroke, and blood clots.
Estrogen-only and estrogen plus progesterone can raise the risk of stroke and blood clots, though the risks are rare in women between 50 and 59.
MHT is normally not recommended for women with a history of:
Breast or endometrial cancer
Stroke or blood clots
Heart disease
Liver disease
Gallbladder disease
It’s also not considered safe for pregnant women.
Your provider can help you understand the risks and benefits and help you determine whether hormone therapy is the right choice.
When should I start — and stop — menopause hormone therapy?
Everyone’s level of tolerance is different. It’s up to you and your provider to decide whether to pursue MHT and when to start and stop. When you are ready to end treatment, your provider may taper you off the medication instead of having you quit cold turkey.
What are the side effects of menopause hormone therapy?
Like any medication, MHT has potential side effects, that may include:
Bloating
Breast discomfort
Temporary spotting or bleeding
Headaches
If your side effects become an issue for you, talk to your provider.
Are there alternatives to menopause hormone therapy?
Yes, there are other ways to treat menopause symptoms. Some to consider:
Non-hormone medications, such as fezolinetant for hot flashes, antidepressants for hot flashes, selective estrogen modulators (SERMs) for hot flashes or pain during sex, and gabapentin for hot flashes and sleep problems.
Vaginal moisturizers and lubricants, which you can pick up at your local drugstore without a prescription.
Herbal and plant supplements, such as relizen and black cohosh for hot flashes.
Menopause symptoms can be incredibly disruptive for some women, and considering all the treatments out there, there’s no reason to suffer. Be sure to find a provider who’s well-versed in the research and can help you find the choice that’s right for you. To find a menopause practitioner near you, visit the North American Menopause Society.
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