If you’ve been struggling with menopause symptoms, you’ve likely heard whispers about Menopausal Hormone Therapy (MHT). Once a topic of confusion and lots of debate, MHT (also known as Hormone Replacement Therapy (HRT) or Hormone Therapy (HT)) is now understood as the most effective treatment for managing menopause symptoms that can make the menopause transition feel like an uphill battle.

Here we outline some of the essential facts to help you understand MHT.

What Exactly is MHT?

As you approach menopause, your body’s natural production of hormones (like estrogen and progesterone) begin to fluctuate and then eventually drop. This decline is what triggers those uncomfortable symptoms that impact your quality of life. MHT works by supplementing these hormones, bringing them back to a level that helps your body function more comfortably. It is important to note that MHT typically uses much lower doses of hormones as compared to combined hormonal contraceptives (like birth control medications).

Not all MHT is the Same: Systemic vs Local

One of the most important things to know is that there are two primary ways MHT is delivered:

• Systemic Therapy: These hormones (most commonly in the form of pills, patches, or gels) get absorbed into the body either through your gastrointestinal tract or through your skin (the transdermal route) and travel through your entire bloodstream. This is the best option for treating "whole-body" symptoms such as vasomotor symptoms (hot flashes, night sweats). It also provides the added benefit of protecting your bones against osteoporosis.^1-3 Since the entire body is exposed to hormones, systemic MHT carries potential risks such as blood clots, stroke, or breast cancer in some individuals, so overall health history and risk factors must be carefully considered.^1,2
• Local Therapy: These are vaginal hormone products that act solely within the vaginal, vulvar and pelvic floor tissues to reduce genital and urinary symptoms such as vaginal dryness, irritation, painful intercourse, and urinary urgency. These products can be in the form of vaginal creams and tablets/ovules/rings inserted vaginally. Because very little enters the bloodstream, it carries minimal risk and is safe for long-term use for most women, even in those who may not be candidates for systemic hormone therapy.^1,2

Why We Ask About Your Uterus

If you are considering systemic therapy, whether you still have your uterus matters:^1,2

• If you have a uterus: You must take progesterone alongside estrogen. This is because estrogen alone can cause the lining of the uterus to thicken, increasing the risk of endometrial cancer. Progesterone protects that endometrial lining from uncontrolled growth. There are newer forms of MHT now on the market that allow systemic hormone effects to be prescribed without requiring a separate prescription for progesterone.
• If you’ve had a hysterectomy: You can safely take estrogen alone.

Timing is Everything

You may have heard scary headlines about the risks of hormone therapy from years ago. Current research now shows that timing matters significantly for when MHT is started. MHT is generally considered safest and most effective when started in women under age 60 or within 10 years of their menopause onset.^1,2 When started in this "window," the risks of complications like blood clots or heart disease are much lower.

During perimenopause, combined hormonal contraceptives (instead of MHT) can be considered and are helpful for changing menstrual cycles, as they not only ease symptoms like hot flashes but also regulate menstrual cycles, reduce heavy or painful periods, and provide reliable contraception.⁴ However, when the menstrual cycles stop and you have reached menopause, the use of combined hormonal contraceptives should be reviewed by a healthcare provider and treatment changed.

It’s Not Just About Hot Flashes

While symptom relief is the main reason women seek MHT, it offers other major health perks:

• Bone Health: It helps prevent bone loss and reduces the risk of fractures.
• Early Menopause Protection: For women who enter menopause early (before age 45) or prematurely (before age 40), MHT is often strongly recommended to protect against long-term risks. In these cases where menopause arrives earlier, MHT is usually recommended until the age of natural menopause, which is around 51.

MHT is used primarily to treat disruptive symptoms such as hot flashes, night sweats, difficulty sleeping, mood changes, and vaginal dryness or pain with sex.^1,2 These indications for MHT represent the conditions with the strongest evidence supporting use. While MHT is sometimes prescribed off label for other menopausal symptoms such as joint pain, brain fog, or cognitive changes, the evidence for these uses is less robust and requires individualized assessment with your healthcare provider. MHT is also not recommended for the prevention of heart disease or cognitive decline in women who go through menopause at the usual age, because large randomized controlled trials, have shown that MHT does not reduce the risk of coronary heart disease, stroke, or dementia when used solely for these purposes.³

You Have Options With MHT

In Canada, you can choose from various delivery methods based on your lifestyle. Transdermal options (patches and gels) have the hormones absorb through the skin to provide a more consistent level of hormone in the body throughout the day, and are often considered safer options for women with risk factors such as high blood pressure, clotting risks, or migraines.^1,2 Pills taken by mouth have advantages such as familiar administration method, once daily dosing, reliable absorption patterns and often covered by most drug plans.

Furthermore, many common prescription products are structurally identical to the hormones your body naturally produces. This means you don't need to seek out expensive, unregulated "natural" compounded products to get "bioidentical" benefits. Compounded “bioidentical” hormone therapy is marketed as more natural, however, these products are not regulated by Health Canada and are not proven to be safer or more effective than approved prescription therapies.^1,5

So, is MHT right for you?

MHT is a highly personalized choice. The right choice of hormone therapy for you depends on your age and time since menopause, symptom severity, personal and family medical history, individual risk factors, personal preferences for delivery method, and lifestyle factors. However, there are still risks and side effects associated with MHT that should be reviewed to ensure it is a right fit for you.

If you're under 60 and your symptoms are impacting your work, sleep, or overall quality of life, it's worth having an informed discussion with your healthcare provider to weigh your personal history against the benefits of therapy.

Some women should not use systemic MHT or may need to stop using it if they begin experiencing undesirable side effects. Systemic MHT is not appropriate for women with a personal history of breast or estrogen-sensitive cancers, unexplained vaginal bleeding, blood clots, stroke, coronary artery disease, or active liver disease.^1,2 If you're already on MHT, tell your healthcare provider right away if you develop any of these conditions. They may want to change your treatment plan or adjust your dose.

Once MHT is prescribed, it is important to continue having regular follow-up with a healthcare provider to ensure that therapy is both effective and well tolerated.

Learn More about MHT

For more information, reliable patient-friendly resources are available through:

• Society of Obstetricians and Gynaecologists of Canada (Menopause and U): https://www.menopauseandu.ca/
• Canadian Menopause Society- Menopause Hub: https://www.canadianmenopausesociety.org/professionals/menopause-hub/
• The Menopause Foundation of Canada: https://menopausefoundationcanada.ca/resources/
• The Menopause Society: https://menopause.org/patient-education