Menopausal Hormone Therapy

Women who are unable to cope with menopausal symptoms to the extent that it interferes with quality of life can consider Menopausal Hormone Therapy (MHT). MHT was at one time referred to as HRT (hormone replacement therapy).

Replacing the lost estrogen that occurs with menopause helps women cope with their symptoms better. Estrogen is  replaced either in the form of tablets, patches or creams.

Women who have had their uterus taken out for various reasons, need only take estrogen hormones.

Estrogen is always combined with progestins when a woman has her uterus intact. 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.

Women who have their uterus intact need estrogen and at least 10 -12 days of progestins every month.

Women with an intact uterus need 2 hormones i.e. estrogen and progestin. This is called combined hormone therapy (HT). There are two types of combined HT available:

Sequential HT: This is for perimenopausal women who are still having menstrual bleeding either regularly or irregularly; and having symptoms of menopause which do not allow them to function normally in their day to day activities. In sequential HT, estrogen is given daily and progestins 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 progestins 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.

There are different types of estrogen preparations available.

Hormone therapy (HT) can be given in various ways.

a) Oral route as tablets to swallow. This is the most common route in Malaysia.
b) Non oral routes such as:

Patches are not available in Malaysia.

Estrogen gel is available and women can apply a prescribed amount over the upper shoulder or thigh daily.

Progestins are available as oral or vaginal tablets. Alternately she may consider inserting the LNG (progestin) Intra Uterine System (IUS) into the uterus for endometrial protection.

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.

Before prescribing HT, 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.

Benefits of MHT

• Relief of vasomotor symptoms such as hot flushes, night sweats, tiredness, aches and pains, mood swings, sleep problems etc.
• Improvement in energy levels.
• Improvement in dryness of skin.
• Improvement in quality of hair.
• Improvement in urogenital symptoms leading to better vaginal health, less pain during sexual activity and lesser risk of infections of the bladder and vagina.
• Improvement in libido.
• Decreases risk of recurrent urine infections and improves urinary incontinence.
• Decrease in total cholesterol and LDL (bad cholesterol) levels. This improves the cardiovascular status of the heart and decreases risk of heart blocks (atherosclerosis). Non oral HT has been shown to be more beneficial to the heart.
• Improvement of bone density and decrease in fracture risk.
• Improvement in balance and reduces tendency to fall.
• Decreases risk of osteoarthritis.
• Improvement in quality of health.
• Decreases risk of diabetes mellitus.
• Decreases risk of colorectal cancer.
• Decreases risk of breast cancer in women (without a uterus) who only take estrogen.
• Preserves teeth with a lesser risk of osteoporosis of jaw.
• Decreases risk of cataract formation, dry eyes and age related macular degeneration.

MHT does not help in

• Improvement of memory.
• Age related dementia or degeneration.
• Improvement in Alzheimer’s disease.

Risks of MHT

• Stroke risk. A very small increased risk of stroke in both combined HT and estrogen only users who take hormones orally. Non oral HT users have no increased risk of stroke.
• 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.
• Breast cancer: A very small increase which equates to 6.8 additional cases per 1000 women per five years for combined HT users. No increased risk in estrogen only users if used for less than 6 years.
• Small increase in gall bladder disease.
• A small increase in flares if the post menopausal woman has systemic lupus erythromatosis (SLE).

There is no increased risk of lung or ovarian cancer

Your doctor would also  not put you on hormone therapy if

• you have breast cancer
• you 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

Side Effects of HT

It is quite common for the body to take time to adjust to the hormones in your body. The common side effects are breast tenderness, bloating, headaches, nausea. To lessen these effects, the dose of MHT can be changed or the delivery method could be fine tunes.

Many women are worried about weight gain. However a meta-analysis of 28 trials found no evidence of increase in weight or body mass index with either estrogen only use or estrogen / progestin use.

An increase in pigmentation may occur but allergic reactions are rare.


Duration of Use

The two main factors that have questioned the duration of use of MHT is the increased risk of breast cancer and the effect of MHT on coronary heart disease.

Breast Cancer

Combined MHT  ( in women with an intact uterus) users showed a higher risk of breast cancer and breast cancer mortality after 4-5 years of use in the WHI (Women’s Health Initiative) study, while the estrogen only users did not show any increased risk after 6 years of continuous use.

Coronary heart disease (CHD)

Younger post-menopausal women on both estrogen / progestin (combined MHT) do not show an increased risk of  cardiovascular, stroke or  VTE risk.

The younger post menopausal woman (50-59 years)  on estrogen only MHT  showed a significantly lower risk of CHD and heart attacks (myocardial infarction).

General recommendations advice that MHT use is safe in the younger menopausal woman (within 10 years of menopause).

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.