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For decades, hormone therapy for people navigating menopause has been underprescribed and misunderstood, often seen as risky or unnecessary. But that’s changing.
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More patients are asking about menopause hormone therapy (MHT), more health care providers are prescribing it, and growing evidence supports its safety and efficacy at improving quality of life during midlife and beyond. The inclusion of MHT in pharmacare agreements signed between the federal government and the provinces of Manitoba and British Columbia further reflects the growing recognition of its value as a treatment option.
When I work with my patients, here are the top five things we review about MHT to help guide their decision-making about whether it is the right choice for them.
What is MHT, exactly?
You might be more familiar with the term HRT or hormone replacement therapy. But recently, the preferred term has become menopause hormone therapy, or MHT, because the goal isn’t to replace something but rather to treat the symptoms of menopause effectively. Same treatment, more accurate name.
During the transition to menopause, your ovaries produce less estrogen and progesterone. This can lead to symptoms such as hot flashes, night sweats, sleep issues, brain fog, mood changes, vaginal dryness and changes in sexual function. MHT is intended to help ease these symptoms.
MHT can be taken as estrogen only, or estrogen combined with progestogens (various forms of synthetic and bioidentical progesterone). It comes in the form of patches, gels, pills, vaginal tablets or creams.
What are the main reasons MHT is used?
The main, evidence-based uses for MHT, endorsed by the major menopause societies worldwide, are for treating vasomotor symptoms (hot flashes and night sweats), preventing osteoporosis and treating genitourinary syndrome of menopause (changes to the vaginal and bladder tissues).
For those who enter menopause early, especially before age 40, MHT is often recommended until the average age of natural menopause (around 51), since early loss of estrogen can increase the risk of heart disease and osteoporosis.
What types of MHT are there?
Systemic MHT, which is absorbed into the bloodstream and has effects throughout the body, comes in the form of transdermal options such as estrogen patches, gels or oral pills. If you still have a uterus, combined therapy that also includes progestogen is always recommended to protect the uterine lining and reduce the risk of endometrial cancer. However, if you’ve had a hysterectomy, you may not need the progestogen.
Then there’s local vaginal estrogen, which is used for genitourinary symptoms including vaginal irritation, bladder changes, or recurrent urinary tract infections. It is applied directly to the vaginal and vulvar tissues and delivered at a significantly lower dose than systemic (whole body) hormone therapy. It can be started at any age, and as I often share with my patients, it’s treatment you can use “till death do you part.”
You may have also heard of “custom-compounded” hormones, which are prepared by a pharmacist according to an individualized recipe prescribed to a patient and are often marketed as more natural. However, these medications are not approved by Health Canada. The Society of Obstetricians and Gynaecologists of Canada says they raise safety concerns.
What are the risks of MHT?
While MHT is considered safe for most people under 60 or within 10 years of menopause, understanding the risks is key to making an informed choice.
There’s a small increased risk of blood clots and stroke with oral estrogen, which is one reason why transdermal options, such as estrogen patches or gels, are often preferred as they carry a lower risk and are generally considered safer for most.
The conversation around breast cancer and hormone therapy can feel confusing. What we know: using estrogen and progestogen together (for those who have a uterus) is linked to a small increased risk of breast cancer when used for more than five years. That risk decreases after stopping treatment. For those who’ve had a hysterectomy and use estrogen alone, current data show a reduced risk of breast cancer.
How do I know whether MHT is right for me?
There is no specific test doctors use to determine what treatment option is best for patients experiencing menopause symptoms. I make recommendations to my patients based on their individual symptoms, the impact on their daily lives, their health history and their goals of care.
Knowing whether MHT is right for you involves an individualized approach, considering your personal and family health history, a risk assessment for clotting, cancer and heart disease, and your treatment goals. If MHT isn’t a fit, you can consider other options such as lifestyle modifications and non-hormonal medications.
Working with your health care provider to understand your symptoms and how they affect your life is the first step. Menopause is often overlooked as a cause for changes in energy, focus and sleep, which are frequently attributed to midlife stress or aging. This ignores the impact of unmanaged menopause symptoms that can have significant downstream effects beyond the physical effects – on work performance, personal relationships and mental health. The Menopause Foundation of Canada estimates the cost of unmanaged menopause symptoms is $3.5-billion per year from factors such as missed work, reduced hours, or early retirement.
Supporting people through menopause benefits everyone.
Dr. Sheila Wijayasinghe, known as Dr. Sheila to her patients, is a menopause and sex therapy certified family physician practising at St. Michael’s Hospital in Toronto, and the medical director of primary care outreach at Women’s College Hospital. She is also the resident health expert on CTV’s The Social, and co-host of The Doc Talk Podcast. Dr. Sheila is dedicated to improving access to care and supporting individuals in achieving better health outcomes and confidently navigating the health care system.
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