Menopause Hormone Therapy: Is it right for me?
Menopausal hormone therapy (MHT) is considered the most effective treatment for vasomotor symptoms such as hot flashes and night sweats. In addition to symptom relief, MHT may also improve sleep, mood changes, and genitourinary symptoms of menopause (GSM), while helping to maintain bone health and reduce bone loss.
MHT typically includes estrogen combined with a progestogen for individuals with a uterus, or estrogen alone for those who have had a hysterectomy. Current guidelines support the safe initiation of MHT in appropriately screened individuals who are younger than 60 years old or within 10 years of menopause onset, provided there are no contraindications.
In Canada, estrogen therapy is available in several forms, including oral tablets, transdermal patches and gels, and local vaginal estrogen products. Vaginal estrogen is primarily used to treat GSM symptoms locally with minimal systemic absorption. Progestogen options include oral medications, combination estrogen-progestogen patches, and the off-label use of a levonorgestrel intrauterine system (IUS).
Additional hormone therapy options that do not require separate progestogen include tissue selective estrogen complexes (TSECs), which combine conjugated estrogen with bazedoxifene, as well as tibolone, a medication with estrogenic, progestogenic, and androgenic effects through its active metabolites.
Who should not take MHT?
While we aim to provide effective treatment and symptom relief for individuals experiencing perimenopause and menopause, menopausal hormone therapy (MHT) is not appropriate for everyone. Responsible prescribing requires careful consideration of each individual’s medical history, symptoms, risk factors, and treatment goals to ensure the benefits outweigh the potential risks. As a result, MHT may not be recommended for all patients, and alternative treatment options may be discussed when appropriate.
Contraindications to systemic menopausal hormone therapy include the following:
Contraindications to estrogen:
Undiagnosed abnormal vaginal bleeding
Active breast cancer, suspected breast cancer, or a personal history of breast cancer
Active estrogen-dependent cancers or suspected estrogen-dependent cancers (i.e., endometrial, ovarian)
Coronary heart disease
Active venous thromboembolism or history of venous thromboembolism
Active stroke or history of stroke
Known thrombophilia
Active liver disease
Known or suspected pregnancy
Uncontrolled hypertension
Contraindications to progestogen:
Undiagnosed abnormal vaginal bleeding
Active breast cancer or personal history of breast cancer
Though not absolute contraindications for MHT, the below factors may increase risk of adverse events related to MHT:
High risk for breast cancer (eg. BRCA mutation, strong family history)
Coronary heart disease risk factors
Active gallbladder disease
Migraine with aura
Obesity
