21/01/2026
Menopausal Hormone therapy :
A step by step guide to MHT:
Step 1 - Assess if MHT is right for the patient
Step 2 – Hormonal therapy options
Step 3 – Starting MHT treatment
Step 4 – Follow-up
Step 5 – Stopping treatment
Step 1 - Assess if MHT is right for the patient:
MHT indications-
➢Vasomotor symptoms
➢Prevention of bone loss
➢Premature hypoestrogenism
Hormone therapy is approved for women with hypogonadism, POI or premature surgical menopause
➢Genitourinary symptoms
MHT contraindications -
➢Unexplained vaginal bleeding
➢Severe active liver disease
➢Prior estrogen-sensitive breast or endometrial cancer
➢Coronary heart disease (CHD)
➢Stroke
➢Dementia
➢Personal history or inherited high risk of thromboembolic disease
➢Porphyria cutanea tarda
➢Hypertriglyceridemia
Main risk factors for HT use-
➢Older age (>60 years)
➢Obesity (BMI > 30 kg/m2)
➢Insulin resistance
➢Increase cardiovascular risk (dyslipidaemia, hypertension, diabetes mellitus, smoking)
➢Personal or family history of venous thromboembolism (VTE)
Step 2 - Hormonal therapy options:
Basics of MHT-
➢Estrogen replacement therapy: for women without a uterus
➢Estrogen–progestogen therapy: For women with intact uterus
MHT options:
➢MHT is the most effective treatment for VMS
➢Oestrogen alone (E) - in hysterectomised women
➢Oestrogen plus Progestogen (E&P)
– For endometrial protection
– Cyclical regimen in peri - & early post menopause
– Continuous in women more than 1 year post menopause
➢Low dose OC pill in women 60 years, transdermal HT or an ultra-low-dose oral product may be more appropriate than conventional-dose systemic HT
➢In obese women, the transdermal route is preferred
➢Oral oestradiol has greater positive impact than transdermal HT on insulin resistance and is the option of choice in non-obese patients with impaired glucose tolerance
➢Some evidence to support use of transdermal HT in women with increased cerebrovascular risk
Tissue Selective Oestrogen Complex (TSEC)
Selective Estrogen Receptor Modulator + Estrogen
➢Differing agonist or antagonist effects at the oestrogen receptor in different tissues > “selective”. The outcome is distinct from administering either component alone.
➢Available 2017 - CEE 0.45mg with Bazedoxifene 20mg (Duavive)
–Improves hot flushes, sleep
–Improves BMD
–Neutral effect on the endometrium
–Improves VVA symptoms
–Less bleeding than with CEE/MPA
–Less mastalgia then CEE/MPA
–For use in postmenopausal women with a uterus
Step – 3 Starting MHT treatment
➢International guidelines recommend that HT be started as soon as menopausal signs or symptoms appear which, in most women, is between 45 and 55 years of age
➢Women with primary ovarian insufficiency require earlier and continued use of HT (at least until the normal age of menopause) to protect against associated postmenopausal chronic diseases
Cyclical/sequential HT:
➢Cyclical or sequential HT involves daily administration of oestrogen, with the addition of progestogen for 12-14 days a month (monthly bleeds) or for 12-14 days every 13 weeks (bleeds every 3 months)
➢Causes regular progestogen withdrawal bleeds, which may be of value for patients new to HT who have been experiencing irregular bleedings due to their perimenopausal stage
➢Any irregular bleeding and/ or spotting that occurs in addition to regular progestogen withdrawal bleeds can be managed by increasing the oestrogen dose as this stabilizes the endometrium
Continuous HT
➢Continuous administration of both oestrogen and progestogen, but at a lower progestogen dose which may minimize associated breast cancer risk; this regimen eliminates withdrawal bleeding and promotes amenorrhea
➢Should be used only in women who are at least 2 years past their last menstrual period as it can cause irregular bleeding in perimenopausal women due to the unpredictable residual production of oestradiol by remaining primordial ovarian follicles
The impact of micronized progesterone on
the endometrium: a systematic review
An international expert panel’s recommendations on MHT containing micronized progesterone are as follows
➢Oral micronized progesterone provides endometrial protection if applied sequentially for 12–14 days/month at 200mg/day for up to 5 years
➢Vaginal micronized progesterone may provide endometrial protection if applied sequentially for at least 10 days/month at 4% (45 mg/day) or every other day at 100mg/day for up to 3–5 years (off-label use)
➢Transdermal micronized progesterone does not provide endometrial protection
Evaluating risk factors for MHT in candidate patients
Questions to ask
•Age
•Menstruation status
•Menopausal symptoms
•Past and current medical history
•Family history
•Lifestyle factors (e.g. smoking, alcohol use, exercise)
•Concurrent medications
Examinations/investigations to perform:
•Body weight
•Waist circumference
•Blood pressure
•Blood tests if indicated by responses to questioning
•Imaging (e.g. ultrasound, bone density) if indicated by responses to questioning
•Mammography if not performed within previous year
•Bone densitometry (dual-energy x-ray absorptiometry) if patient at risk for osteoporosis
Starting MHT treatment
Address her concerns:
➢Localised urogenital symptoms
–vaginal lubricants, moisturizers
–vaginal E therapy--- does not require progestogen possibly MHT
➢Moderate to severe menopausal symptoms
–hormonal Tx = E (no uterus), E+P, E + BZA, Tibolone
–non hormonal options
➢Sexual dysfunction
–consider tibolone/testosterone therapy
➢Concerns, no distressing symptoms
–advice on lifestyle management
–evidenced based information
Step 4 – Follow-up
➢Schedule a follow-up appointment after initiation of a MHT regimen, e.g. in one month, to assess treatment effect
➢Adverse effects of MHT include bloating, breast tenderness, increased blood pressure, headaches, fluid retention and urinary incontinence
Persistent vasomotor symptoms
➢Increase MHT doses or try another formulation
Breast tenderness
➢Reduce the dose of oestrogen or switch to another progestogen
➢If tenderness remains on further follow-up, consider discontinuing MHT, switching patients to tibolone, or prescribing conjugated equine oestrogens + bazedoxifene (not funded)
Unscheduled bleeding in the first 3 months-
➢Consider continuing treatment unless there is a high suspicion of endometrial cancer as bleeding may settle with time
➢Other options include:
oSwitching to cyclical progestogen for patients taking continuous progestogen
oIncreasing the dose of progestogen
oSwitching from oral progestogen to a levonorgestrel IUD
Unscheduled bleeding after the first three to six months of MHT:
➢Organise further investigations for endometrial cancer
➢If no endometrial pathology is detected, consider increasing oestrogen dose
Step 5 – Stopping Treatment
➢Current users of HT can remain on treatment indefinitely (lifelong if indicated), or at least until such time as the patient asks to stop
➢Regular monitoring of HT is advised, with adjustments made to type, dosage and/ or route of administration according to a patient’s changing circumstances and treatment goals
