MHT: THE NEW TERM FOR HRT
Menopausal Hormone Therapy (MHT), previously known as Hormone Replacement Therapy (HRT), is recommended as the most effective treatment for the symptoms of menopause.
WHAT IS MHT?
Menopausal hormone therapy (MHT) consists of oestrogen, with or without a progestogen, and is recommended for the treatment of the symptoms of menopause.
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.
For women who have had a hysterectomy, oestrogen alone may be a suitable treatment for menopause symptoms. However, women who still have a uterus require MHT that also contains a progestogen in order to protect the uterine lining (the endometrium). MHT is the most effective treatment for hot flushes and night sweats, as well as many other symptoms of 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.
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MHT is the most effective treatment for the symptoms of menopause.
MHT types
MHT differs by 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 and 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 oestrogen. However, those with a history of severe endometriosis or a “sub-total” hysterectomy (where the cervix is left in place) should discuss the use of combined MHT with their doctor.
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.
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 libido 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 of MHT
In addition to being the most effective treatment for menopausal symptoms, there are other potential health benefits of MHT.
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 there is also evidence that MHT might reduce joint pain and stiffness.
Type 2 diabetes
The rates of diabetes increase substantially during mid-life, and taking MHT can reduce the risk of type 2 diabetes in post-menopausal women. Whilst MHT itself is not a treatment for diabetes, it is also important to note that having type 2 diabetes is not a contraindication to starting MHT.
Heart disease
For women without risk factors who start MHT within 10 years of their last period, or before the age of 60, there does not appear to be any 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 very small and appears to be mostly associated with the progestogen component of MHT.
For combined MHT, there is a very small increased risk of breast cancer, which increases the longer you use MHT. This risk decreases again after stopping MHT. The risk might also be lower with different types of progestogen.
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.
See the above section on the benefits of MHT.
As for heart disease, there does not appear to be an increased risk of stroke in women who do not have risk factors and who start MHT within 10 years of their last period, or before the age of 60. 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.
Oral 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.
Transdermal oestrogen preparations (gels or patches) have little or no impact on the risk of VTE and are preferred for women with VTE risk factors.
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.
SUMMARY
MHT is the most effective treatment for symptoms of menopause, including hot flushes and night sweats. It is also a safe treatment 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, the benefits of MHT may still outweigh the risks. However, a careful discussion with your doctor is required. Different types of MHT have different risks, and the transdermal options (gels and patches) may be the safest option for most women.