Combined Menopausal Hormone Therapy (MHT)

Key Points 

  • MHT is the most effective treatment for hot flushes and night sweats.
  • Only women with an intact uterus need the addition of a progestogen.
  • The risks are small in most women within 10 years of their final menstrual period.
  • Non-oral routes of administration have fewer risks than oral preparations.
  • See AMS information sheet AMS Guide to Equivalent MHT/HRT Doses for a list of products available in Australia and New Zealand. 

pdfAMS Menopause Combined MHT376.24 KB

The menopause is the final menstrual period and usually happens between the ages of 45 and 55 years. Around this time, women may experience symptoms such as hot flushes, sweating, vaginal dryness, loss of libido, irritability, sleep disturbance and muscle/joint pains. Oestrogen therapy is the most effective means of treating these symptoms. It will also prevent bone loss.

In a woman with an intact uterus, unopposed oestrogen therapy increases the risk of endometrial hyperplasia and cancer (1). Therefore, women who have not had a hysterectomy should take a progestogen as well to provide endometrial protection. Note that there is no therapeutic advantage of prescribing progestogen (either a progestin or natural progesterone) to women who have had a hysterectomy, (with the possible exception of women with symptomatic residual intra-peritoneal endometriosis) (2). In fact, there is a distinct disadvantage in terms of increased breast cancer and thrombotic risk and adverse changes in cardiovascular risk factors (3). (See information sheet on Risks and Benefits of MHT/HRT)

Combined menopausal hormone therapy may be given as "cyclical", where the oestrogen is given daily and the progestogen is given for 10-14 days of the month, or "continuous" where both oestrogen and progestogen are given daily. "Cyclical" produces withdrawal vaginal bleeds whereas "continuous" should not.

As a general rule, cyclical hormone therapy is used for a woman who is in the menopausal transition and is having some irregular spontaneous menses or is very recently postmenopausal, but it can be continued longer if preferred. Continuous hormone therapy is a convenience often preferred by older women. Early introduction of continuous MHT close to the menopausal transition may lead to irregular, unscheduled breakthrough bleeding. Breakthrough bleeding may occur in the first six months of any MHT regimen but any unscheduled bleeding after that should be investigated.

Combination packs of either cyclical or continuous preparations are available. These improve medication compliance and ensure reliable endometrial exposure to progestogen. If, for reasons of intolerance to either the formulation or the mode of delivery, it is thought necessary to "mix and match" oestrogen and progestogen preparations, it is important to emphasise to the patient that reliable endometrial protection depends upon sufficient progestogen exposure (4).

Types of oestrogens

Types of progestogens

Other MHT

Before prescribing

Choice and adjustment of therapeutic regimens

The benefits of MHT

Managing the risk

Continuation or cessation of combined MHT

September 2018

References

  1. Furness S, Roberts H, Marjoribanks J, Lethaby A. Hormone therapy in postmenopausal women and risk of endometrial hyperplasia. Cochrane Database of Systematic Reviews. 2012;8:CD000402.
  2. Al Kadri H, Hassan S, Al-Fozan HM, Hajeer A. Hormone therapy for endometriosis and surgical menopause. Cochrane Database of Systematic Reviews. 2009(1):CD005997.
  3. Manson JE, Chlebowski RT, Stefanick ML, et al. Menopausal hormone therapy and health outcomes during the intervention and extended poststopping phases of the Women's Health Initiative randomized trials. JAMA. 2013 Oct 2;310(13):1353-68.
  4. Schindler AE. Progestogen deficiency and endometrial cancer risk. Maturitas. 2009 Apr 20;62(4):334-7.
  5. Canonico M, Plu-Bureau G, Lowe GDO, Scarabin P-Y. Hormone replacement therapy and risk of venous thromboembolism in postmenopausal women: systematic review and meta-analysis. BMJ. 2008 May 31;336(7655):1227-31.
  6. Stanczyk FZ. All progestins are not created equal. Steroids. 2003 Nov;68(10-13):879-90.
  7. Elshafie MAA, Ewies AAA. Transdermal natural progesterone cream for postmenopausal women: inconsistent data and complex pharmacokinetics. J Obstet Gynaecol. 2007 Oct;27(7):655-9.
  8. Davis SR, Castelo-Branco C, Chedraui P, et al. Understanding weight gain at menopause. Climacteric. 2012 Oct;15(5):419-29.
  9. de Villiers TJ, Pines A, Panay N, et al. Updated 2013 International Menopause Society recommendations on menopausal hormone therapy and preventive strategies for midlife health. Climacteric. 2013 Jun;16(3):316-37.
  10. Mikkola TS, Tuomikoski P, Lyytinen H, et al. Increased cardiovascular mortality risk in women discontinuing postmenopausal hormone therapy. J Clin Endocrinol Metab. 2015 Dec;100(12):4588-94.
  11. Karim R, Dell RM, Greene DF, Mack WJ, Gallagher JC, Hodis HN. Hip fracture in postmenopausal women after cessation of hormone therapy: results from a prospective study in a large health management organization. Menopause. 2011 Nov;18(11):1172-7.

 

AMS Empowering Menopausal Women

Note: Medical and scientific information provided and endorsed by the Australasian Menopause Society might not be relevant to a particular person's circumstances and should always be discussed with that person's own healthcare provider.

This Information Sheet may contain copyright or otherwise protected material. Reproduction of this Information Sheet by Australasian Menopause Society Members and other health professionals for clinical practice is permissible. Any other use of this information (hardcopy and electronic versions) must be agreed to and approved by the Australasian Menopause Society.

Content updated 12 September 2018

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