MHT: THE NEW TERM FOR HRT
Menopausal Hormone Therapy (MHT), previously known as Hormone Replacement Therapy (HRT), is one of the most common and effective treatments for certain menopause symptoms, especially vasomotor symptoms such as hot flushes.
WHAT IS MHT?
Menopausal Hormone Therapy (MHT) is a prescription-only medication that consists of an oestrogen, with or without a progestogen, and is one of the treatments that your doctor might recommend for menopause-related symptoms. It is available in various doses and routes, such as tablets, gels or patches.
Whilst MHT affects many aspects of health, it is mainly recommended for the management of menopausal symptoms.
How does MHT work?
The negative symptoms of perimenopause and menopause are primarily due to falling oestrogen levels, which decline with age and drop suddenly at menopause. This event is a normal part of life, however, individual women can experience it differently. Oestrogen receptors (which the body uses to sense oestrogen levels) are present throughout the body, from the reproductive system to the bones to the brain, explaining why dropping oestrogen levels can be associated with such a wide variety of symptoms.
MHT works by replacing these declining oestrogen levels to address the associated symptoms of menopause.
The primary benefits of MHT come from the oestrogen it provides, and for women who have had a hysterectomy oestrogen alone may be a suitable treatment for menopause symptoms. However, oestrogen alone stimulates the lining of the womb (the endometrium) to grow, so women who still have a uterus require MHT that also contains a progestogen in order to prevent this.
MHT is the most effective treatment for vasomotor symptoms of menopause such as hot flushes and night sweats. It can also help to alleviate other symptoms of menopause, such as vaginal dryness and discomfort and mood symptoms associated with menopause.
Current research shows that MHT is a safe and effective treatment for the symptoms of menopause for most women if commenced within 10 years of natural menopause or before the age of 60. Whilst these age limits are not strict, increasing age is associated with an increased risk of other health conditions such as cardiovascular disease, so a careful and individualised discussion about the risks and benefits of MHT is required if you are considering starting MHT outside these timeframes.
For women who go through menopause earlier than expected, before the age of 45, MHT is recommended at least until the average age of menopause (51 years) due to the beneficial health effects.
Can everyone take mht?
MHT is not a suitable treatment for all women, and there are certain medical conditions in which it should not be prescribed. These include a personal history of breast cancer or undiagnosed abnormal vaginal bleeding. Special care needs to be taken with some other medical conditions, including in those with a history of certain other cancers, heart disease, blood clots, stroke, or liver disease. The risks and benefits of MHT need to be carefully considered in these situations, and should be discussed with a specialist.
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MHT is the most effective treatment for the symptoms of menopause.
MHT types
MHT differs in the type of hormones they contain as well as the way in which they are taken.
Oestrogen only or combined MHT?
Most women take a combination of oestrogen and progestogen (known as combined MHT). Oestrogen is the hormone that treats the symptoms of menopause. In women with a uterus it is important to take a progestogen to prevent overgrowth of the lining of the uterus (the endometrium). Women who do not have a uterus can usually take just estrogen. However, those with a history of severe endometriosis or a “sub-total” hysterectomy (where the cervix is left in place) should discuss with their doctor whether combined or oestrogen-only MHT is a better option for them.
Continuous or sequential combined MHT?
For women who use oestrogen-only MHT, the medication will generally be the same each day. However, for women using combined MHT, treatment is available in either continuous or sequential preparations. Continuous combined MHT consists of the same dose of oestrogen and progestogen each day and is the most frequently used type.
For women within a year of their last period, continuous MHT can often lead to unexpected and unpredictable vaginal spotting or bleeding, and for this reason cyclic MHT treatment is recommended. This usually consists of two weeks of combined oestrogen and progestogen treatment followed by two weeks of oestrogen-only treatment, during which a small amount of vaginal bleeding is expected to occur in a predictable fashion, known as a “withdrawal bleed”. After 12 months, or when withdrawal bleeding ceases, most women can switch to a continuous preparation.
Route of administration
The oestrogen component of MHT can be administered as an oral tablet, a skin patch or a gel, whilst the progestogen component can also be administered as an oral tablet, a skin patch, or an IUD (intrauterine device) called a Mirena. These can be combined into a single tablet or patch, or prescribed as two separate medications, depending on which you choose.
There are advantages and disadvantages to each of the different routes of administration in terms of side effects and risks, as well as convenience and tolerability for each patient. Choosing which is right for you will depend on your medical history, lifestyle, and what works best in your situation. This can sometimes take some trial and error, and women will often try a few different options before settling on one that works best for them.
Topical vaginal oestrogen
Oestrogen can also be prescribed as a vaginal cream or pessary (tablet), which is recommended for the management of genitourinary symptoms of menopause such as vaginal dryness. This can be used alone, or in addition to systemic MHT.
Testosterone
Testosterone is not considered a component of MHT. However, it is prescribed to some women in addition to MHT to help with low libido. There is evidence that it can help improve sexual satisfaction and desire in post-menopausal women, though it is not suitable for everyone and should be trialled under the guidance of your doctor. It is important to talk to your GP or gynaecologist if you are symptomatic or concerned about the long-term effects of the menopause or of your MHT, to provide a personalised treatment plan.
The benefits and risks of MHT
In addition to being the most effective treatment for vasomotor symptoms of menopause, there are other potential health benefits of MHT. Overall, for most women with menopausal symptoms the benefits of MHT likely outweigh the risks.
Osteoporosis and fractures
The drop in oestrogen that occurs with menopause leads to a reduction in bone density, which can ultimately lead to osteoporosis (thin bones) and the resulting increased risk of fractures. Taking MHT helps maintain bone density and reduces the risk of fractures. There is also some evidence that MHT might reduce joint pain and stiffness.
Type 2 diabetes
The risk of developing diabetes increases substantially during mid-life. This risk is not increased by taking MHT, and having type 2 diabetes is not a contraindication to starting MHT.
Heart disease
For women without risk factors who start combined MHT within 10 years of their last period, or before the age of 60, there does not appear to be an increased risk of heart disease. For women who can take oestrogen-only MHT, there may even be a reduction in the risk of heart disease if started during this timeframe. There may be an increased risk of heart disease for women starting MHT outside these times, and it is important to discuss your specific situation and risk factors with your doctor.
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Taking MHT helps maintain bone density.
The risks of MHT
Although MHT is the most effective treatment for the symptoms of menopause, as with all medications it has other risks and benefits. Overall, advice from medical experts is that the benefits of MHT outweigh the risks for healthy women experiencing symptoms during menopause. When considering the added risks of taking MHT, many of them are rare and are comparable to other risk factors such as being overweight or drinking alcohol.
Breast cancer is the most common cancer in Australian women, and 1 in 7 will develop it during their lifetime. The additional risk from taking MHT is small and appears to be mostly associated with the progestogen component of MHT.
For combined MHT, there is a small increased risk of breast cancer, which increases the longer you use MHT. This risk decreases again after stopping MHT, however, it stays elevated for at least 10 years after ceasing. The risk might be lower with different types of progestogen, however, more research is required to be certain about this.
For women taking oestrogen-only MHT, the risk of breast cancer is lower than for women taking combined MHT. It is thought that there is either no increased risk, or a very small increased risk for these women.
Continuous combined MHT decreases the risk of endometrial cancer (cancer of the womb), however, the risk may be slightly increased with sequential combined MHT. Oestrogen-only MHT should not be used in women who still have a uterus.
There appears to be a very small increase in the risk of ovarian cancer in women using either combined or oestrogen-only MHT, however the risk of ovarian cancer in women less than 60 years’ old remains very low.
For women who start MHT before the age of 60, there is a very small increase in the risk of stroke when taking combined MHT that includes an oral oestrogen. For women taking combined MHT with a transdermal oestrogen, there is probably no increase in the risk of stroke. This includes both combined and oestrogen-only MHT. For women who do have underlying risk factors, MHT may still be appropriate, however, a transdermal oestrogen such as a gel or patch is preferable.
MHT that includes transdermal oestrogen (i.e. via gel or patch) does not increase the risk of venous thromboembolism (VTE – or blood clots). For this reason, women with risk factors for VTE are generally advised to use a transdermal preparation.
Oral combined MHT doubles a woman’s baseline venous thromboembolism (VTE – or blood clots) risk. However, the absolute risk of VTE for women on oral MHT is low, increasing to ~2 per 1000 women per year compared to 1 per 1000 women per year in non-users. The absolute risk will be higher in women with co-existing VTE risk factors such as smoking and obesity. The risk of VTE also increases with age.
Combined MHT, if started after the age of 65, might slightly increase the risk of dementia. Oestrogen-only MHT probably has no impact on the risk of dementia.
Overall, the risks of MHT must be considered in perspective for each woman and balanced against the benefits. The choice of MHT should be individualised to minimise risk and guided by the severity of symptoms. Your doctor can help you understand the MHT treatment plan according to your individual needs, symptoms and risk factors.
HOW LONG BEFORE SYMPTOMS IMPROVE?
It usually takes several weeks before you feel the initial benefits of MHT. The full effect may take up to three months. It may also take your body time to adjust to MHT.
When you first take MHT, you may experience side effects such as breast tenderness and swelling, irregular bleeding, fluid retention, bloating and nausea. These symptoms often subside with time, though occasionally they can be a sign of a serious underlying medical condition. Therefore, if these side effects persist, see your doctor to arrange additional tests, and to consider a different type of MHT or a dosage adjustment.
STOPPING MHT
There are no hard and fast rules when it comes to the maximum duration of MHT treatment, or a specific age at which it should be ceased. However, the balance between risks and benefits change as women get older and as new health issues arise. It is therefore important to have regular reviews with your prescribing doctor to discuss whether MHT is still the right option for you.
When ceasing MHT, it is important to be aware that symptoms may return. In this case, depending on other risk factors, some women will choose to restart their treatment. This decision requires a careful and personalised discussion with your doctor that takes into account your individual circumstances.
SUMMARY
MHT is the most effective treatment for several symptoms of menopause, including hot flushes and night sweats. The benefits of treatment probably outweigh the risks for most women if started within 10 years of menopause or before the age of 60. For women who are outside these ranges and who have menopausal symptoms, MHT may still be considered, however, a careful discussion with your doctor is required that considered your individual risk factors.