Dr Sanjay Kalra elucidates the definition, indications and contraindications along with the various formulations that are incorporated in menopause hormone therapy (MHT). Also discussed are some pragmatic tips to help initiate the use of MHT in a safe and smart manner, in women living with menopause.

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Understanding menopause

Menopause is a physiological phase which occurs in every woman’s life, provided she lives long enough to experience it. Multiple concerns, however, emerge during this time like:

• Vasomotor metabolic
• Musculoskeletal
• Mood swings
• Micturition/Local genital tract
• Malignancy-related issues

These can be managed by a skillfully crafted prescription of lifestyle modification, non-hormonal therapy and management. Due to various misunderstandings and miscommunications, “hormones” are sometimes considered a “dangerous” medication. Nothing can be further from the truth.

In a hormone-panic individual, effective hormone replacement or supplementation is safe, and well-tolerated, provided it is accompanied by medical supervision. Menopause hormone therapy (MHT) offers the promise of better health to women passing through menopause and addresses the various symptoms and limitations that may accompany this phase of life.

MHT has been used safely in women for many decades. Thus, this form of management has achieved what we term ‘midlife maturity’. At the same time, we keep on learning newer facets of MHT, and hence the therapy continues to exude ‘maiden charm’.

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What is MHT?

MHT can be defined as the rational use of hormonal preparations to alleviate symptoms, dysfunction and concerns associated with menopause. Multiple preparations are available for this purpose, and their choice depends upon the needs, concerns and preferences of the individual woman.

The vanguard of MHT is composed of two hormones estrogen (E) and progesterone/progestin (P). Choosing the right E and P preparation, route of administration, and duration of therapy is the cornerstone of successful MHT.

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Indications of MHT

MHT is indicated in women with symptoms of menopause, and in women who exhibit signs of osteopenia. Women with “surrogate” laboratory or imaging results that reflect menopause-associated dysmetabolism may also be candidates for MHT.

These indications include symptoms, signs and significant laboratory/imaging abnormalities (such as osteoporosis and sarcopenia) should prompt screening for concerns and contraindications related to MHT.

MHT is strongly indicated in women with vasomotor symptoms such as hot sweats, and genitourinary complaints such as urgency and frequency of micturition, as well as vaginal/ vulval dryness, irritation or itching. MHT should be considered if signs such as loss of rugosity, or thin/ atrophic vagina are noted, along with labial atrophy. Significant abnormalities in investigations like bone density can also be an indication of MHT.

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Contraindications

There are very few absolute contraindications to the use of MHT. These are malignancies of the breast and the female genital tract. Uncontrolled hypertension and a high risk of venous thromboembolism are other situations where a careful Risk : Benefit analysis must be performed before the prescription.

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Pre-medication counselling

Comprehensive pre-medication counselling is required before starting any long-term therapy, and MHT is no exception. The BLACK mnemonic (Benefits, Limitations, possible Adverse effects, Cost/coverage and Knowledge/skills required to take MHT safely) reminds us of the various aspects of medication counselling. Sharing of information leads to a state of “information equipoise”, which facilitates a balanced risk: benefit analysis and shared decision making.

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Pre-medication screening

Gynaecological, psychological, medical/ metabolic and endocrine screening is mandatory before starting MHT. The main aim of screening is to rule out breast or genital malignancy and manage metabolic dysfunction concomitantly with MHT.

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Person-centred choice

A wide variety of drugs and preparations exist in MHT. The therapy can be offered as oral, injectable, transdermal or vaginal preparations. The hormones include estrogen and progesterone. In general, MHT should be started swiftly, to alleviate symptoms, and used for a short period, to meet pre-decided endpoints. Low dose MHT can be used for longer periods up to 10 years, or till age 60.

Vaginal estrogen creams can be used for local genitourinary symptoms, but oral and transdermal routes are more effective in managing the entire spectrum of menopausal symptoms and concerns. Transdermal estrogen is preferred in elder women, those who are obese, and those at high risk of venous thromboembolism.

These can be used as continuous or sequential therapy. The table below describes some of the oral combinations of MHT that are used in women with an intact uterus. Women without an intact uterus can take unopposed estrogen as well. It must be noted that MHT differs from combined oral contraceptives in the quality of its composition (natural vs synthetic) and estrogenic activity (mild vs intense).

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Effectiveness of MHT

MHT is an effective means of improving health and alleviating concerns or symptoms in women living through menopause. MHT should be used under medical supervision, with comprehensive screening and regular monitoring.

Various oral MHT formulations

E= estradiol hemihydrate; P= dydrogesterone

Disclaimer- The views and opinions expressed in the article and videos are those of the speakers and do not necessarily reflect the official policy or position of M3 India.

The author, Dr. Sanjay Kalra is a leading Endocrinologist from India.