Menopause hormone therapy (MHT) is used to alleviate the symptoms of declining ovarian hormones and improve quality of life during the menopause transition and post-menopause. Traditionally known as hormone replacement therapy (HRT), MHT can include estrogen, or a combination of estrogen and progesterone, and sometimes testosterone.
Available as pills, patches, gels, creams, sprays, rings, or IUDs, MHT administration methods vary to accommodate each individual’s needs.
Below, we discuss the clinical guidelines as to why one method of MHT is prescribed above another and how transparency with your healthcare provider can ensure the correct type of MHT is suggested for you.
What is Menopause Hormone Therapy (MHT)?
MHT involves supplementing estrogen, progesterone, and sometimes testosterone to re-balance hormone fluctuations during menopause and ease the associated symptoms as hormone production declines.
While testosterone levels are known to decrease before perimenopause, estrogen and progesterone typically begin to decline between the ages of 45-55, but it can happen earlier or later for some.
Common menopause symptoms can include irregular menstruation, hot flashes, night sweats, fragmented sleep, mood alterations, drier skin, joint pains, low libido, and difficulty focusing.
As well as easing symptoms and improving a woman’s quality of life throughout the menopause transition, MHT can help prevent more serious conditions from occurring after menopause.
Although MHT is referred to as menopause hormone therapy, female health experts recommend that women begin taking it during the transition to menopause, which is known as perimenopause.
Women then reach menopause when menstruation has not occurred for 12 consecutive months, after which they are considered postmenopausal.
Menopause Symptoms: Why They Occur?
Throughout life, estrogen, progesterone, and testosterone work in tandem to support menstruation, reproduction, and pregnancy. Independently, each of these hormones also plays a supporting role in other parts of the body.
For instance, estrogen supports the brain, bones, heart, skin, muscles, and vagina. Progesterone helps to stabilize moods, promote sleep, build bone, and support the uterine lining. And testosterone helps regulate the female sex drive, sleep, and energy levels.
Therefore, when the production of these hormones begins to fluctuate during perimenopause, the physiological changes occurring in the body can impact more than just a woman’s reproductive system.
Anxiety, fatigue, and brain fog can be side effects of estrogen and progesterone imbalance during the menopause transition, for example. Low libido, fatigue, and mood alterations can be caused by changing testosterone levels.
Deficient estrogen levels can also inhibit bone growth and increase the risk of developing osteoporosis and cardiovascular disease post-menopause. The muscles & joints can weaken due to hormone imbalances during, and after, menopause resulting in more aches and pains and often less physical activity.
Unfortunately, metabolism and fat distribution are also altered by the gradual decline in hormone production, and coupled with inactivity, is often the cause of abdominal weight gain during menopause.
To rebalance fluctuating hormones and alleviate menopause symptoms, MHT involves the supplementation of estrogen, progesterone, and sometimes testosterone - depending on each individual’s symptoms.
As symptoms ease, quality of life is generally improved, a sense of mental clarity is restored, and the onset of more serious conditions after menopause can be avoided.
Why Are There Different Types of Menopause Hormone Therapy?
The decline in hormone production during perimenopause does not happen in the same way or similar timeframe for all women. Additionally, hormone levels don’t consistently decline during perimenopause. Instead, production levels fluctuate erratically and gradually decline over time.
This means that symptoms can vary from patient to patient and range from mild to severe. This is why individualizing MHT according to each patient is recommended.
Vital factors considered when prescribing one type of MHT over another are; the patient’s age, symptoms, family history, where they are on their menopause journey, and whether they’ve had a hysterectomy.
Depending on the answers to the above questions, MHT is prescribed in different combinations, administration methods, and doses to accommodate each woman’s needs.
Are There Risks or Side Effects to Taking HRT?
Some side effects and risks have been linked to MHT since it was first approved by the FDA in the 1940s. However, new research shows that risks linked to MHT from older studies were quite small, incorrectly presented, and do not apply to all women.
In the 1970s, for instance, studies linked estrogen-only therapy to an increased risk of endometrial cancer. Updated research, however, proved that adding progesterone to MHT could protect the uterine lining from hyperplasia and prevent endometrial cancer.
Another study carried out by the Women’s Health Initiative (WHI) in 2002 incorrectly generalized that all forms of MHT increased the risk of breast cancer, blood clots, and stroke. After this study, the use of MHT dropped considerably and left many women with no help in managing menopause symptoms.
However, new research debunked these risks for women with no history of clotting and showed that MHT can also be adapted to treat women with a history of blood clotting. In subsequent studies, the risk of developing breast cancer from MHT was also found to be much smaller than previously thought.
The book Estrogen Matters by Avrum Bluming MD and Carol Tavris PhD explains how minimal this risk is by pointing out that women (without a history of breast cancer) who take MHT for 10 years have a 96% chance of staying free of breast cancer. In comparison, women who do not take MHT have a 98% chance of remaining free of breast cancer.
The 2% variation is not linked to estrogen supplementation but rather the type of progestin used in combined hormone therapy.
Considering that the risk of developing breast cancer from drinking three glasses of wine per week is 15%, the link to an increased risk of breast cancer when taking MHT is minuscule in comparison.
Side effects linked to MHT include breast tenderness, bloating, vaginal bleeding, and mild skin irritation. Even though these can be temporarily bothersome, studies show that MHT side effects typically subside once the body adjusts to the types of supplemented hormones.
Which Type of MHT is Right for You?
One size of MHT does not fit all individuals and some women may find that they have been prescribed a different type of MHT to their friends. This is normal and usually based on one or more of the above-mentioned side effects or risk factors.
To understand the variables of MHT and which one is right for you, it’s best to start with an evaluation from a menopause expert or female healthcare provider. The evaluation will include questions about your medical history, symptoms, age, menopause journey so far, underlying conditions, and whether you’ve had a hysterectomy.
Answering honestly will help your healthcare practitioner prescribe the most suitable type, dose, and combination of MHT for you.
Scheduling regular check-ups after starting MHT will also help your healthcare provider monitor your progress and amend your dose or combination as you progress through menopause.
The Most Common Methods of Administering MHT
Due to the numerous symptoms associated with menopause and how a woman’s medical history can influence the effects of supplemented hormones, MHT administration methods have evolved since it was first developed in the 1940s.
For instance, bioidentical (natural) hormones are now as widely available as the traditionally used synthetic hormones.
Bioidentical hormones are derived from plants like soy and yams and then processed in a lab to create effective medicine. While both bioidentical and synthetic hormones are considered safe and beneficial, one may be recommended above the other in certain situations.
The following are the most common types of MHT and why they are recommended:
Local Hormone Therapy
Local hormone therapy is used to treat symptoms associated with one area of the body during peri and post-menopause. Typically used to treat genitourinary symptoms, which include issues affecting the bladder, vagina, vulva, or urethra, local hormone therapy is administered as a cream, vaginal suppository, or vaginal ring.
Genitourinary symptoms can include vaginal dryness (atrophy), vaginal or vulvar irritation, urinary issues, increased bladder infections, and pain or discomfort during sex (dyspareunia).
Estrogen creams are produced with bioidentical or synthetic hormones, while vaginal suppositories or rings are bioidentical.
Systemic MHT
In contrast to local MHT, systemic MHT is absorbed throughout the body and treats several menopause symptoms. Systemic MHT can include estrogen-only or estrogen with progesterone and is typically administered in pill form or transdermally via skin patches, gels, or sprays.
Estrogen Pills
Estrogen pills have been well-researched and are a safe and effective form of hormone therapy for alleviating several menopause symptoms in most women. In addition to hot flashes, estrogen can also help improve moods, dry skin, anxiety, body aches, and bone growth.
For women whose uterus is intact, progesterone is normally taken in conjunction with estrogen pills to protect the uterine lining and prevent endometrial cancer.
Women who have undergone a hysterectomy can safely take estrogen pills without progesterone. However, progesterone is also safe for women after a hysterectomy and can be taken to improve sleep, moods, and bone growth.
Due to the slightly increased risk of clotting and stroke when taking estrogen pills, they are typically not prescribed for women with liver issues. Oral estrogen is broken down by the liver and can increase the risk of clotting in women with liver issues, a history of blood clots, or a condition that increases the risk of clotting.
Estrogen pills can also decrease sex drive in some women. As it passes through the liver, oral estrogen increases the production of sex hormone binding globulin (SHBG), a protein produced in the liver.
Responsible for transporting the sex hormones and regulating their distribution around the body to ensure they are available where needed, SHBG is essential for hormone balance but overproduction can sometimes affect the female libido.
Estrogen Patches, Gels, or Sprays
Research has shown that transdermal estrogen administered via patches, gels, or sprays carries no risk of clotting and stroke. The risk is eliminated because estrogen is absorbed through the skin rather than passing through the liver.
In addition to those with liver issues, transdermal estrogen may also be prescribed to patients who smoke, are obese, have high blood pressure, or have a history of blood clotting. Transdermal estrogen may also be a better option for those who take thyroid hormone replacement as transdermal estrogen does not affect the levels of thyroid hormone in the blood, but oral estrogen can.
Vaginal Rings
Vaginal rings are available as systemic or local MHT. Local, estrogen-only vaginal rings are used to reduce genitourinary symptoms associated with menopause such as vaginal dryness, pain during or after sex, and bladder issues.
Systemic vaginal rings include both estrogen and progesterone and are prescribed to treat a variety of menopause symptoms such as hot flashes, mood alterations, and night sweats, as well as genitourinary issues. Systemic vaginal rings can also decrease the loss of bone density and muscle mass during menopause, and help reduce the risk of developing osteoporosis in later years.
Inserted high into the vagina, either by yourself or your healthcare provider, vaginal rings are typically left in place for 90 days before being replaced by a new ring.
Some initial side effects from vaginal rings can include headaches, abdominal pain, or vaginal bleeding but each is known to subside as the body adjusts. Vaginal rings do not interfere with sex and patients should not be able to feel them once inserted.
Progesterone Pills or Intrauterine Devices (IUDs)
When taking systemic estrogen to treat menopause symptoms, progesterone is required to keep the uterine lining healthy and prevent uterine cancer. Progesterone also helps to build bone, stabilize moods, and improve sleep throughout the menopause transition.
For the latter reasons, progesterone is sometimes prescribed for women who have had a hysterectomy, even though it is not required for uterine health. Progesterone is also helpful in treating heavy vaginal bleeding.
In contrast to estrogen, progesterone is not well absorbed by the skin. It is therefore administered as bioidentical progesterone in pill form, synthetic progestin pills, or via an IUD that periodically releases low doses of synthetic progestin.
Combined HRT
Combined MHT contains estrogen and progesterone and is prescribed as pills or patches that are produced with synthetic or bioidentical hormones. In these cases, estrogen and progesterone are typically taken simultaneously using separate administration methods.
Because progesterone is not well absorbed by the skin, a bioidentical estrogen patch can be combined with micronized bioidentical progesterone pills, synthetic progestin pills, or an IUD containing synthetically produced progestin.
Unlike the small risk of blood clotting linked to estrogen pills, micronized progesterone pills do not have this effect.
Testosterone Cream
During perimenopause and postmenopause, bioidentical testosterone is used to treat low libido, mood instability, and low energy levels. It is applied as a gel or cream onto the thigh, groin, wrist, or forearm.
To determine which type of MHT is best for you, schedule a consultation with a trusted healthcare provider or a menopause specialist for an evaluation.
Additional Methods of Easing Menopause Symptoms
In addition to MHT, some small lifestyle changes can help ease menopause symptoms and improve women’s quality of life.
Gentle exercise can help ease weight gain, relieve joint pain, strengthen muscles, and build bone strength in women transitioning through menopause. Exercise can also positively impact women’s mental health while navigating through body changes and bothersome symptoms at this stage of life.
Eating the right foods can have a positive impact on menopause symptoms, provide nutritional support, and prevent weight gain. Speak with a nutritionist about incorporating adequate nutrients like omega-3 fatty acids, protein, fiber, calcium, and vitamin D to maintain optimal health through your menopause journey.
Practicing mindfulness is also beneficial to remember that menopause does not have to be associated with the loss of youth but can instead be a journey of self-acceptance, empowerment, and enlightenment. To improve mindfulness, try meditation, conscious breathing, or a daily walk in the fresh air.
Conclusion
Menopause hormone therapy (MHT), also known as hormone replacement therapy (HRT), is used to ease menopause symptoms and improve women’s quality of life during the perimenopause transition and post-menopause.
MHT typically includes estrogen or a combination of estrogen and progesterone, and occasionally testosterone. Available as pills, gels, patches, sprays, vaginal rings, or IUDs, hormone therapy for menopause can be prescribed to suit each patient’s needs.
Determining which method of MHT is best for each individual typically begins with an evaluation from a menopause expert or female health provider and full disclosure from the patient regarding their age, medical history, and menopause symptoms.
References
National Library of Medicine - Hormone Replacement Therapy - https://www.ncbi.nlm.nih.gov/books/NBK493191/
UCLA Health – 2002 HRT Study Comes Under Criticism - https://www.uclahealth.org/news/article/2002-hrt-study-comes-under-criticism
National Cancer Institute - Menopausal Hormone Therapy and Cancer - https://www.cancer.gov/about-cancer/causes-prevention/risk/hormones/mht-fact-sheet
Cleveland Clinic – Bioidentical Hormones - https://my.clevelandclinic.org/health/treatments/15660-bioidentical-hormones
National Library of Medicine - Use of hormone replacement therapy and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases - https://pubmed.ncbi.nlm.nih.gov/30626577/
Estrogen Matters - The Book That Changed The Conversation About HRT - https://estrogenmatters.com/