MENOPAUSAL HORMONE THERAPY (MHT) : THE NEW HRT
Menopausal Hormone Therapy (MHT), previously known as Hormone Replacement Therapy (HRT), is recommended for the treatment of symptoms of menopause
MHT is the most effective treatment for hot flushes and night sweats, as well as many other symptoms. In women who no longer have a uterus, oestrogen-only therapy is adequate, unless extensive endometriosis or sub-total hysterectomy.
Current research shows that MHT is both a safe and effective way to treat symptoms of menopause in women if commenced within 10 years of natural menopause. MHT should not be initiated after the age of 60. Women who go through menopause before age 45 are advised to take MHT until the average age of the menopause (51 years). The risks of MHT are not significant until after this time. Women taking MHT should be reviewed annually by their GP.
Non-oral routes of administration have slightly less risk than oral preparations. Advice from medical experts is that the benefits of MHT far outweigh the risks for healthy women experiencing symptoms during the menopause.
The main risks of MHT are breast cancer, cardiovascular disease, and thromboembolic disease. In a recent study, there were three extra cases of breast cancer per 10,000 women for oestrogen alone and nine extra cases per 10,000 women for oestrogen plus progesterone use. (Vinogradova et al., 2020) The risk is increased with a longer duration of use, particularly in older women (>age 60). The risk decreased after MHT was stopped.
A review of MHT and its relationship to cardiovascular risk has concluded that there is no strong evidence for protection or harm from MHT with respect to cardiovascular disease overall. (Boardman HM, CR 2015) For women who started MHT within 10 years of their last period, there was evidence of reduced mortality or protection from coronary heart disease.
The absolute risk of venous thromboembolism (clots) for women on oral MHT is low: 2-3 per 1000 women years compared to 1 per 1000 women years in non-users. Oral MHT doubles a woman’s baseline VTE risk. The absolute risk will be higher in women with co-existing VTE risk factors such as smoking and obesity.
The risks of MHT must be considered in perspective for each woman and balanced against the benefits. The choice of MHT must 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 and particular symptoms.
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Only 13% of women in Australia are on MHT (50-69 age group)
How does MHT work?
MHT helps to relieve symptoms of perimenopause and menopause by replacing oestrogen, which naturally declines with age. MHT also offers protection against bone loss and fractures, cardiovascular disease, type 2 diabetes, clinical depression, colon cancer and dementia.
MHT types
There are many different types of MHT. Most women take a combination of oestrogen and progestogen (known as combined MHT). Some women take testosterone in addition to MHT to help with low libido.
In women with a uterus, it is important to take progesterone to keep the endometrium (lining of the womb) thin and to help reduce the risk of uterine cancer. Women who do not have a uterus can take oestrogen on its own, unless they have extensive endometriosis or a sub-total hysterectomy.
Oestrogens are available as tablets, skin patches or gels and topical vaginal preparations (creams, pessaries and tablets). The term progestogens includes both natural progesterone and synthetic preparations. Progestogens are mostly taken orally but are also available as tablets, skin patches, or hormonal intrauterine system (IUS). Micronised progesterone capsules are a form of natural, or ‘body-identical’ progesterone recently available in Australia. Wild yam (progesterone cream) should not be used in MHT due to its lack of safety.
The skin patches and gels are absorbed through the skin and enter the bloodstream directly, thereby avoiding the liver and reducing the risk of blood clotting. Patches or gels are better for women who have malabsorption issues or high triglyceride concentrations, a past history of VTE (clots), migraines, untreated hypertension, or significant liver disease. This includes women who are overweight or smokers due to the increased risk of VTE.
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. However, if these side effects persist, you may need to see your doctor for a different type of MHT or dosage adjustment.
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Almost two-thirds of women experience brain fog as a symptom of menopause
MHT and preventing disease
MHT reduces the risk of various chronic conditions that can affect postmenopausal women, including osteoporosis (a thinning of the bones) and reduce risk of fractures, cardiovascular disease (when taken within 10 years of the menopause), obesity and diabetes, depression and dementia (limited studies indicate a reduced risk of developing Alzheimer’s and other types of dementia) and colon cancer.