What is Menopausal Hormone Therapy (MHT)?
Note: The terminology “Menopausal Hormone Therapy (MHT)” has replaced “Hormone Replacement Therapy (HRT)”
Menopausal Hormone Therapy (MHT) are preparations that contains female hormone estrogen or a combination of estrogen and progestogen. MHT replaces the loss of estrogen that occurs with menopause and helps women cope with their symptoms better.
Who should take MHT?
MHT is recommended to women who experience menopausal symptoms that affect their quality of life. It is also advised for women to prevent or manage chronic conditions that may occur with menopause, such as genitourinary symptoms and osteoporosis.
General recommendations advice that MHT use is safe in healthy women with symptoms, who are less than 60 years old or within 10 years of menopause, who have no contraindications for MHT.
How should I take MHT?
Women who have had their uterus taken out for various reasons, need only take estrogen hormones.
Women who still have their uterus need to take a combination of 2 hormones i.e. estrogen and progestogen. This is called combined hormone therapy (HT). In such women, taking estrogen alone can increase the thickness of the lining of her uterus and cause bleeding problems, hyperplasia (over activity of the uterine lining) or even cancer of the uterus in the future.
There are two types of combined HT available:
Cyclical HT:
This type of HT is for perimenopausal women who are still having menstrual bleeding either regularly or irregularly
Estrogen is given daily and progestogens are added for at least 10-12 days.
She will experience regular monthly bleeding.
Continuous combined HT:
This type of HT is for women who are officially menopaused or had their last period one year ago.
Estrogen and progestogens are taken daily.
The woman may experience some bleeding during the initial 4 months. After which, if correctly taken without any missed tablets, she will not experience any more bleeding.
What are the different types of MHT available? MHT may be delivered via oral, transdermal and intrauterine routes.
Estrogen
Estrogen is replaced either in the form of tablets, patches, creams or spray.
There are different types of estrogen preparations available.
Oral route as tablets to swallow. This is the most common route in Malaysia.
Non oral routes such as:
Estrogen gel or spray: women can apply a prescribed amount over the upper shoulder or thigh daily.
Patches are not available in Malaysia.
c) Low dose vaginal estrogen:
Available as cream or tablet (which is in combination with probiotics) and is suited for women with genitourinary syndrome of menopause (GSM)
Progestogens
Progestogens are available as oral, vaginal tablets or the intrauterine system (IUS)
Why are there different types of MHT and different routes of delivery (oral/non-oral)?
Different preparations available allow you and your doctor to choose a treatment that suits your needs and lifestyle.
The advantage of the non-oral route is that it avoids the liver and very suited for women with liver problems, high cholesterol levels, high risk of clotting problems, obesity or chronic migraine.
Using a non oral route of HT lowers the risk of deep vein thrombosis (blood clots), stroke and heart attack.
How do I know which type of MHT would be the most suitable for me?
Before prescribing MHT, your doctor would probably take a good history and carry out a gynaecological examination.
It would be good to provide a detailed family history of cardiovascular disease, migraines, deep vein thrombosis, cancers and osteoporosis.
Blood pressure values, height and weight measurements and BMI would be tabulated.
A pap smear (where relevant), a pelvic ultrasound and mammography is ideal as baseline investigations and again at regular intervals.
Bone mineral density tests is encouraged for women with a high risk of fracture.
Your doctor would then carry out a risk / benefit assessment based on your symptoms, your health and existing medical and family history.
What are the benefits of MHT?
In general, MHT will help improve your quality of health and quality of life by relieving your symptoms.
Will MHT help to improve my memory or prevent dementia or Alzheimer’s disease?
Unfortunately, MHT does not help with improvement of memory, age related dementia or Alzheimer’s disease.
What are the risks of MHT?
Risks of MHT differ with the type of estrogen or progestogens used, duration of use, route of administration, timing of initiation and whether estrogen or an estrogen/progestogen combination is prescribed.
Some of the most common concerns when initiating MHT are as follows:
Concern on the risk of breast cancer:
Present data has shown that
In women without a uterus, the use of estrogen up to 5 years and more does not increase breast cancer risk.
In women with a uterus, some studies show one extra case of breast cancer in 70 women when estrogen & progestogen are taken for more than 5 years. However, with the use of safer hormones now, this risk is also decreased.
This risk is so small compared to other common risk factors that increase the risk of breast cancer such as being overweight, having a sedentary lifestyle, not having children or not breastfeeding.
Concern on the risk of stroke:
MHT is advised for women in the perimenopause and within 10 years of their last period.
In this group of women, MHT is safe, improves cholesterol levels and does not increase the risk of stroke or cardiovascular disease.
Concern on the risk of venous thromboembolism (VTE) or clots in the blood vessels:
A very small increased risk in oral users of estrogen and combined HT users.
No increased risk of VTE in non-oral HT users.
Are there groups of women who cannot take MHT?
Your doctor would not put you on hormone therapy if you:
have breast cancer
• are pregnant
• have a estrogen dependant cancer
• have abnormal vaginal bleeding
• have history of clotting problems
• have had bad reactions to hormone therapy in your past
What are the side effects of MHT?
It is quite common for the body to take time to adjust to the hormones in your body. You may experience some bleeding during the initial 4 months. After which, if MHT is correctly taken without any missed tablets, you will not experience any more bleeding.
Here are some of the possible side effects of estrogen and progestogen preparations:
Is there a way to lessen the side effects of MHT?
To lessen the side effects, the dose of MHT can be changed or the delivery method could be fine tuned.
Will MHT make me gain weight?
Many women are worried about weight gain. However, research has found no evidence of increase in weight or body mass index with either estrogen only use or estrogen / progestogen use.
What if I missed my MHT pills/dose?
Missing a pill may cause irregular bleeding.
If you have missed a pill, you should take the missed pill as soon as you remember.
You should take the next pill at the usual time.
If you have missed two or more pills, do not take more than one pill to replace the missed pills.
I have taken my MHT as prescribed by doctor, but I am having irregular bleeding. What should I do?
In the initial months of starting MHT, you may experience some irregular bleeding or “breakthrough bleeding” .
Your doctor may increase the dose, type or regime of your MHT to overcome this.
Any unscheduled bleeding beyond 6 months of use of MHT must be investigated.
How long can I be on MHT?
There is presently no time limit for the duration of MHT use.
Every woman on MHT should be regularly followed up and should have a risk/ benefit assessment carried out yearly.