1. It's dangerous.

Confused about menopausal hormone therapy (MHT)? You’re not alone.  

In recent decades, oestrogen therapy, or what used to be called hormone replacement therapy (HRT), has swung from being hugely popular in the 1990s to largely rejected in the 2000s, and is now back to popular again! 

If you want a deep dive on MHT first, don't forget to jump to this article.

When MHT is mentioned, the hormone that usually comes to mind is oestrogen. So, is oestrogen the medicine for the ‘disease’ of menopause? Or is oestrogen a dangerous cause of breast cancer? In truth, hormone therapy is neither of those things. Let’s do a little myth-busting. 

"Hormone Therapy is Dangerous"

MHT has been around since the 1960s, but concerns around hormone therapy started with the infamous Women’s Health Initiative (WHI) study, which was abruptly halted in 2002 because of what seemed to be a worrying link between hormone therapy and both heart disease and breast cancer.  

Twenty years later, scientists agree that the study was flawed:  

1. First, the study only prescribed hormones to older women who were many years past menopause, meaning that the results shouldn’t be applied to premenopausal women or women in the earlier stages of the menopause.  
2. Second, the study linked the risk of heart disease and breast cancer to all oestrogens and progestins, even though only one type of each hormone was used (conjugated oestrogens and medroxyprogesterone).  
3. Third, the methods used to analyse the results were unconventional.  

Most experts now agree that oestrogen therapy is a lot safer than was suggested by the WHI study, including Professor JoAnn Manson who was one of the study’s lead authors. She says the evidence now suggests that the benefits of oestrogen outweigh its risks for younger women just entering menopause, but it’s been tough to get the word out. “There were all these alarm bells that went off in 2002," she says, “and once a bell is rung, it cannot be unrung.”  

Specifically, in terms of heart disease, starting oestrogen therapy at the right time (before you turn 60 or within ten years of the menopause) may reduce the risk of heart disease, not raise it. And in terms of breast cancer, oestrogen alone is linked to a small and, in some cases, no increased risk. Although combined MHT is associated with a small increase in risk of breast cancer, this is only the case for as long as you are on it – the risk reduces once MHT is stopped. The risk is also much smaller if micronised progesterone is used in a combined HRT regimen rather than synthetic progestogens. 

To learn more about the difference between micronised and synthetic progestogens, click here.  

Finally, to put things in perspective, there are several larger risk factors for both heart disease and breast cancer. The best examples are smoking, which dramatically increases the risk of heart disease, and alcohol, which significantly increases the risk of breast cancer.

2. It's Used to Treat "Oestrogen Deficiency"

If you’ve heard something about ‘menopause being a disease of oestrogen deficiency’ or ‘oestrogen to prevent ageing, heart disease and dementia,’ then you may understandably be thinking you should take some!  

In fact, neither of those claims is accurate.  

First, menopause is not a disease of oestrogen deficiency but is instead a normal life event, akin to puberty. “Something that is a normal part of the life cycle cannot at the same time be a cause of major disease and debility,” says Canadian endocrinology professor Jerilynn Prior, referring to the low oestrogen levels seen throughout the menopause.  

As proof of the inherent normality of menopause, consider the fact that women have generally outlived men. That’s true in every culture and throughout history — long before access to hormone therapy.  

Second, although there has been some research around using oestrogen therapy in other areas, at the moment there’s no strong evidence it can prevent ageing, heart disease or dementia. As it stands, oestrogen therapy is only prescribed for:  

• menopause symptom relief  
• reduction of long-term health risks associated with early or medically induced menopause
• the prevention of osteoporosis, but only for women at higher risk 

So, yes. You should definitely consider hormone therapy for menopause symptoms, early menopause, and/or if you are at high risk of osteoporosis. If you have none of those things and feel healthy and well, then you may not need hormone therapy — but speak with your doctor.  

3. It causes weight gain.

If you’re worried about hormone therapy because you think it might cause weight gain, rest assured – there is no evidence to suggest that MHT will cause you to gain weight. You may gain some weight during the menopause because you may lose muscle mass, which means you will need fewer calories – but this tends to happen whether you take MHT or not. That said, there are studies to suggest that MHT can diminish abdominal weight gain. 

The hormones (which are usually prescribed in combination with other oestrogen) that can cause weight gain are:  

1. testosterone
2. androgenic (testosterone-like) progestogens, like levonorgestrel and norethisterone.  

 Usually, weight gain and other side effects of testosterone and androgenic progestogens will improve once the dose is reduced, or the hormone treatment is stopped.

4. You can't take it in perimenopause.

Most so-called ‘menopausal symptoms’ are more likely to occur during perimenopause, which is the two to ten years before your final period.  

So, if you’re in your forties (or even your late thirties) and experiencing symptoms such as night sweats, migraines and mood swings, ask your doctor, ‘Could this be perimenopause?’ Don’t accept the answer that, ‘You’re too young to be in menopause. Come back when your periods stop.’   

Because by then, your symptoms might have settled down! According to Professor Jerilynn Prior, “Women need to know that perimenopause ends in a kinder and calmer phase of life appropriately called menopause.”  

 According to a new set of recommendations from The UK Menopause All-Party Parliamentary Group, all women should be assessed for perimenopause by their mid-forties, when ‘menopausal symptoms, such as hot flushes and night sweats, can begin.’

5. All hormone therapy is the same.

If you’ve had a bad experience with hormone therapy, you might want to try again with a different formulation. So much depends on the exact form, type, dose, and route of administration.  

Oestrogen

For example, oestrogen can feel very different depending on whether it’s taken orally or absorbed through the skin.   

Low-dose transdermal oestrogen such as patches or gels is usually gentler than higher-dose oral oestrogen.  

And, of course, vaginal oestrogen is the gentlest of all.  

And if you’re wondering whether to go up or down with the dose, keep in mind that high-dose oestrogen can, paradoxically, sometimes produce symptoms of oestrogen deficiency. It can be difficult to work out what’s going on, so discuss your symptoms and potential changes to your treatment with your doctor.. 

Progesterone

Having the right progesterone (or progestin) is even more important. As explained in the [link: Types of hormone therapy article], oral micronised (body-identical) progesterone is usually the best choice as it is safer than progestins and can also have beneficial tranquillising effects for mood and sleep.   

If you do take progesterone, be sure to take it at bedtime, or it can make you feel very groggy and weird.  

If you use a progestin (such as levonorgestrel in the hormonal IUD), keep in mind that every progestin has different effects and so potentially a different side effects. You might need to try a few to find one you can tolerate.  

Testosterone 

 If you’re experiencing low libido, which hasn’t improved with conventional MHT, and there aren’t any other obvious causes (to do with your relationship for example), a menopause specialist may prescribe you supplementary testosterone. 

However, too much testosterone can cause:  

• acne,  
• hair loss, 
• and weight gain

If you’re experiencing any side effects, it’s important to speak to your doctor so that they can adjust your treatment regimen. Similarly, if you’ve given your MHT enough time to experience its benefits but don’t feel your symptoms have improved, talk to your doctor about changing your treatment – it can seem like a long journey at times, but the results can be worth it in the end!