Starting and stopping MHT

Menopause symptoms can be classified into groups including vasomotor, psychological, physical, sexual and mental health. The most common reason women start menopausal hormone therapy (MHT) is for the relief of vasomotor symptoms such as hot flushes and night sweats. MHT can reduce these symptoms by around 80%. Menopausal symptoms usually last for five years, although they can last as long as 10 years. About 20% of women will experience severe symptoms and 20% will experience minimal or none.

Your GP is the ideal person to discuss starting MHT and it is important that a general health check be conducted, which includes blood pressure and a breast check. This is also a good time to ensure that you are up to date with cancer screening, such as breast, bowel and cervical. Timing to start MHT depends on the severity of symptoms, your menstrual pattern and relevant personal or family history.

There are different preparations of MHT, and it is important to find one that agrees with you. The main types of MHT are oestrogen-only and combined, which include both oestrogen and progesterone. MHT can be taken orally, across the skin (transdermal gel or patch), or as an intrauterine system. The hormone that your body benefits most from is oestrogen, but if you still have a uterus, you also need progesterone, which stops the lining of the uterus (endometrium) from becoming too thick, which can lead to erratic bleeding. Progesterone can be taken as a tablet, by an intrauterine system, or combined with a transdermal or oral oestrogen.

MHT can be started before your last period if you are experiencing menopausal symptoms. The main issue with starting MHT in the perimenopause is that MHT does not suppress ovarian function. So, if there is residual ovarian activity, oestrogen in the MHT can lead to abnormal bleeding. One way to manage this is to insert an IUD, which keeps the lining of the uterus thin. When MHT is started before the menopause, a ‘sequential’ combined preparation can be taken, which factors in the need for a ‘bleed’ at specific times. Usually, sequential MHT should be taken if it has been less than a year since your last period. If it has been more than a year since your last period, you can start a ‘continuous’ combined preparation (‘no-bleed’) that delivers a small, regulated amount of oestrogen and progesterone daily.

It is becoming more apparent that the benefits of MHT outweigh the risks and most experts in the field support women taking MHT. Ideally, women should start MHT before the age of 60 or within 10 years after the menopause. In these instances, standard MHT may reduce the risk of coronary heart disease and all-cause mortality. The increased risk of breast cancer in women over the age of 50 taking MHT is related to the duration of use and may relate to the type of progesterone. This risk is small and often, if a cancer is detected, it is not aggressive. The overall risk is one extra case per year per 1000 women on MHT. The risk decreases after stopping MHT.