Health

MHT: what you need to know before, during and after menopause

MHT can ease hot flushes, improve mood and sleep, support bone health and even boost your libido, but it’s not a one-size-fits-all solution. Here’s what Australian women need to know to make informed choices about hormone therapy in midlife.

By Sabrina Rogers-Anderson

You wake up exhausted and drag yourself through your day. Coffee doesn’t even seem to make a dent in your overwhelming fatigue anymore.

And then there’s the anger (or is it rage?) that’s always simmering below the surface. No matter how often you vow to keep your cool, you find yourself snapping at your family before the sun is even up. 

You knew perimenopause and menopause were coming, but you didn't expect them to hit you like a ton of bricks.

From period pain to childbirth, women are accustomed to grinning and bearing discomfort. Plus, there are some scary stories out there about the potential side effects of menopausal hormone therapy (MHT), so many of us are wary of taking anything to ease our symptoms. 

“I was reluctant to go on hormone therapy, but I'd become a hot, flustered, moody insomniac, and I had to do something,” says Sophia. “The treatment made me feel like myself again. The hot flushes eased, I could focus better and I could sleep without waking in a sweaty mess several times a night. It honestly saved my sanity.”

The good news is that MHT has been shown to be safe for most women. Understanding your options and going to your GP appointment armed with a list of questions can help you achieve the best outcomes.

What to expect during perimenopause and menopause

Menopause usually occurs between the ages of 45 and 60 (with an average age of 51), but it can happen earlier or later. You’re officially considered menopausal when you haven’t had a period in 12 months. 

Some women go into menopause overnight due to surgery (such as having their ovaries or uterus removed) or cancer treatment. But for most women, the ovaries gradually stop working over a period of 4 to 6 years known as - you guessed it - perimenopause

During perimenopause and menopause, you might experience: 

  • Irregular periods during perimenopause (less often or more often, longer or shorter, and heavier or lighter) and no period once you reach menopause
  • Mood swings
  • Anxiety or depression
  • Hot flushes and night sweats
  • Weight gain
  • Headaches
  • Disturbed sleep
  • Fatigue or exhaustion
  • Difficulty concentrating
  • Memory problems
  • Low sex drive
  • Sore breasts
  • Vaginal dryness
  • Joint and muscle aches
  • Dry or itchy skin

“When we talk about the menopausal transition, the hormonal changes don’t just start when your periods stop,” says Dr Kelly Teagle, GP and founder of telehealth menopause clinic WellFemme.

“Subtle changes in your hormones can start to happen when you’re still having regular periods. That’s the beginning of perimenopause and it can start as early as your late 30s or early 40s. It’s a very dynamic time and what you’ll need at the beginning [in terms of treatment] won’t be the same as what you need at the end.”

Not sure if you’re experiencing perimenopause or menopause? There’s a free menopausal health assessment tool on the Wellfemme website and the Australasian Menopause Society has a menopause symptom score sheet

How can MHT help?

Formerly called hormone replacement therapy (HRT), MHT can help ease menopausal symptoms caused by low oestrogen by restoring hormone levels. 

There are three main types of MHT. Depending on the type, they may be available as pills, patches, gels, vaginal creams or pessaries.

  • Combined MHT: Women who still have a uterus need an MHT regimen that combines oestrogen and a progestogen (such as progesterone) to reduce the risk of endometrial cancer.

  • Oestrogen-only MHT: After a hysterectomy, only oestrogen is necessary in most cases. Vaginal oestrogens can also be used by virtually all women who have genitourinary symptoms of menopause without the need for a progestogen.

  • Tibolone: This is a synthetic steroid hormone that has some oestrogen, progesterone and testosterone-like effects. Women with and without ovaries or a uterus can use it. It’s a continuous, low-dose alternative to oestrogen therapy that is generally only recommended only for postmenopausal women, and it may be particularly useful for women with low libido.

“The products a woman is offered will depend on her age, medical conditions, risk factors, lifestyle and personal preference,” Dr Kelly explains. “Because every woman responds differently to different hormonal products, some trial and error should be expected.

“See a good doctor who's knowledgeable about perimenopause and menopause, and get an individualised assessment and advice so you can make a fully informed choice.”

MHT, formally called HRT, can help ease menopausal symptoms. 

Research has shown that MHT:

  • Is the most effective treatment for hot flushes, night sweats and vaginal dryness

  • May also improve other symptoms of menopause, including sleep and mood issues, joint pain, sex drive, headaches, dizziness and itchy skin

  • May reduce your risk of osteoporosis, bone fractures, type 2 diabetes, heart disease, cataracts and some types of cancer (including endometrial and colon cancer)

“There aren’t currently any MHT medications approved by the TGA [Therapeutic Goods Administration] specifically for use in perimenopausal women,” says Dr Kelly. “But we often prescribe MHT off label to help perimenopausal women with mood, hot flushes and other symptoms.”

Is MHT safe?

The landmark Women’s Health Initiative (WHI) study examined the effects of MHT on 17,000 menopausal women. When the initial results were released in 2002, the media widely reported that MHT was associated with an increased risk of breast cancer and heart disease, causing panic and a steep drop in MHT prescribing and use.

But a reanalysis of the WHI and later studies found that these initial results were deeply flawed.

MHT has since been found to be safe for women in their 50s or within the first 10 years of the onset of menopause, but there are some small risks to take into consideration:

  • Breast cancer: Research shows oestrogen-only MHT causes either no increase or a very small increase in the risk of breast cancer. The risk is slightly higher with combined MHT, but is still small and decreases when MHT is stopped. Women who have had breast cancer should generally avoid MHT, although vaginal oestrogen at a low dose may be safe.
  • Heart disease: If treatment is started before age 60 or within 10 years of menopause, there’s no increased risk and the chance of heart disease may even be reduced.
  • Blood clots: Patches and gels carry little to no risk. Pills double the risk, but it’s still low with only 1 extra case per 1000 women.
  • Stroke: Oral oestrogens can slightly increase the risk of stroke, but they’re generally still safe for low-risk women in their 50s or within 10 years of menopause. Most women can use patches or gels safely, even those at higher risk for stroke.

“MHT is now universally acknowledged as being low-risk and effective for most women in the menopausal transition, with a few notable caveats in terms of medical conditions,” says Dr Kelly.

MHT isn’t generally suitable for women who have or have had:

  • Breast cancer, endometrial cancer or other hormonal cancers
  • Heart disease
  • Stroke
  • Untreated high blood pressure
  • Liver disease
  • A blood clot in a vein
  • Vaginal bleeding with no known cause

Alternatives to MHT

For women who can’t take MHT because of medical conditions or risk factors, there are several non-hormonal alternatives that can help control hot flushes. These include:

  • Antidepressants such as escitalopram and fluoxetine
  • The anti-seizure medication gabapentin
  • Veoza, one of a new non-hormonal class of medications called NK3 inhibitors that help with vasomotor symptoms (hot flushes and night sweats) 
  • Oxybutinin, which is also used for overactive bladder causing urinary frequency

Lifestyle changes including getting your weight into the healthy range, exercising regularly, eating a healthy diet, quitting smoking, and limiting spicy foods, caffeine and alcohol can also help.

Find out more

Your best source of information and advice is your GP or a doctor specialised in perimenopause and menopause such as those at WellFemme

You can also find more information here:

Feature image: iStock/JLco - Julia Amaral

The information on this page is general information and should not be used to diagnose or treat a health problem or disease. Do not use the information found on this page as a substitute for professional health care advice. Any information you find on this page or on external sites which are linked to on this page should be verified with your professional health care provider.

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