Menopause hormone therapy: What to know about treatment for symptoms like hot flushes and dryness

You may have decided to get help for your menopause symptoms because they have been getting worse over time. Or perhaps, you have one really bad issue that is interfering with your daily life in a big way.  

Hormonal medicines have been scientifically proven to reduce menopause symptoms. Previously referred to as hormone replacement therapy, or HRT, this is now known as menopause hormone therapy (MHT).

“Hormone replacement therapy is the older term, which implies that hormones are being replaced to pre-menopausal levels,” said Associate Professor Rukshini Puvanendran, co-director of KK Menopause Centre.

“Menopause hormone therapy is the latest and more accurate term because it describes the treatment as providing hormones in the right amount to manage menopausal symptoms rather than fully replacing them.”

The unpleasant, painful and uncomfortable symptoms that women get around menopause are largely caused by hormone fluctuations and lower levels of hormones such as oestrogen and progesterone.

A doctor will ascertain if MHT is the right course of action for you as well as the dosage you need. It can be prescribed to manage symptoms as a whole or to target one specific issue.

Assoc Prof Rukshini said that each woman experiences menopause differently so it’s essential to consult a healthcare professional for personalised advice and treatment options.

“There should be a holistic and individualised approach in assessing and advising women, with particular reference to lifestyle advice and dietary modification including optimising weight, stopping smoking, exercising, following a healthy diet and reducing alcohol consumption,” she said.

Other information covered should include risk factors for cardiovascular disease (including raised blood pressure, raised cholesterol and obesity), advice on bone health and osteoporosis as well as cancer risk reduction.

This is in addition to management options including MHT or non-hormonal and alternative therapy, Assoc Prof Rukshini added.

IMPROVING QUALITY OF LIFE

Professor Yong Eu Leong, emeritus consultant at the department of obstetrics and gynaecology at the National University Hospital, started the ongoing Integrated Women’s Health Programme (IWHP) in 2014, and has followed the same group of female participants since

The study focuses on the key health concerns of mid-life Singapore women. It recruited 1,200 women to gain insights on women-specific health issues such as menopause, osteoporosis, anxiety, urinary incontinence, poor sleep and hip fractures.  

In a 2023 study of 1,054 eligible women in the IWHP cohort, 62.6 per cent reported at least one moderate to extremely severe menopausal symptom. However, the rate of MHT use among the women who were postmenopausal was 2.8 per cent.

Prof Yong told CNA Women that, for women who are bothered by hot flushes, MHT should be prescribed as early as possible as this will result in a very significant improvement in their quality of life.

Assoc Prof Rukshini recommended seeing a doctor if you have “very bothersome” menopause symptoms, to optimise your health and quality of life.

She explained that, currently, the most robust scientific evidence regarding menopausal symptoms is on vasomotor symptoms such as hot flushes and night sweats. Some women, but not all, suffer from these for prolonged periods of time, and this can last beyond the age of 60.

“MHT in patches or tablets has been demonstrated scientifically to reduce menopausal symptoms and is indicated for moderate to severe menopausal symptoms such as hot flushes and night sweats,” said Assoc Prof Rukshini.

Night sweats can interfere with sleep, and prolonged periods of poor sleep negatively affect physical as well as mental and cognitive health, she added.

She noted that MHT is generally thought to be safe for most women under the age of 60 and within 10 years of menopause.

“MHT is not recommended for women with a history of breast cancer and other oestrogen-dependent cancers,” said Assoc Prof Rukshini, who is also head of Family Medicine Service at KK Women’s and Children’s Hospital. Oestrogen-dependent cancers are those that need oestrogen to develop and grow, and include breast cancer, as well as some ovarian and uterine cancers.  

It’s crucial to discuss the benefits and risks of MHT with your doctor before starting treatment. Assoc Prof Rukshini added that after equipping them with all the necessary information, doctors need to give their patients space and sufficient time to make an informed decision.

WHICH TYPE OF MHT IS BEST FOR YOU?

The timeline from approaching a doctor to being prescribed MHT varies according to each patient’s unique medical condition, medical history and severity of symptoms, Assoc Prof Rukshini said.

Prof Yong noted that, if there are no contraindications, MHT can be prescribed at the first clinical consultation. The formulation, however, needs to be selected with care after discussion between the doctor and the patient.

“Topical oestrogen creams, applied directly to the skin, have been shown to be the safest form of MHT,” he said.

Assoc Prof Rukshini added that women who have had a hysterectomy are usually prescribed oestrogen-only MHT, in oral or transdermal preparations.

Women who have a womb require combined oestrogen and progesterone preparations. Progesterone is needed to balance the effect of oestrogen hormone therapy on the womb as there is a risk of hyperplasia (abnormal thickening of the womb lining due to excessive cell growth) or womb cancer, she added.

Prof Yong added that micronised progesterone has been shown to be the safest option for this purpose. It can be administered as a pessary (inserted into the vagina) or consumed orally.

The SingHealth website advises women to take these hormonal medications at the same time every day to avoid huge changes in your body's hormones, which can lead to mood changes.

REAPING THE BENEFITS OF MHT

How soon you see results after taking MHT depends on which symptom you’re most concerned about. Prof Yong said that, for hot flushes, women should notice favourable effects within a few days.

Vaginal dryness may take a couple of weeks longer as vaginal tissues need to rejuvenate. For bone health and osteoporosis, he said this might take a few months to years.

With regards to side effects, Assoc Prof Rukshini said the most common ones are breast tenderness and nausea, which resolve within weeks in most women. A rare but serious side effect is venous thromboembolism, such as deep vein thrombosis.

Prof Yong said that if there are no contraindications, topical estradiol with micronised progesterone is a safe form of MHT with respect to venous thromboembolism (blood clots in the veins) and cardiovascular side effects.

If any symptoms persist, highlight them to your doctor, who can make adjustments to the dose and type of MHT.

Women should follow-up with their doctor after three months of starting MHT, said Assoc Prof Rukshini. They should then be reviewed once every six months or yearly as deemed necessary by their doctor. You might need to change dose over the course of time as your normal hormone levels continue to fluctuate.

How long a woman continues to be on MHT is decided on a case-by-case basis.

“As MHT is a tailored approach, the decision to continue with it is made on an individualised basis after discussing the benefits and risks with each patient; it will also be considered in the context of the overall benefits obtained from using MHT,” said Assoc Prof Rukshini.

She added that women with early menopause – before the age of 45 – are usually advised to take MHT until the age of natural menopause if there are no medical reasons that prevent them from doing so.

Prof Yong noted that women may react differently to MHT treatments and suggested that women stick to one medical professional they’re comfortable with. “If the patient is uncomfortable with any issue, she should go back to her doctor for further discussion,” he said.

“MHT needs to be taken for long periods and adjustments may need to be made from time to time depending on new symptomatology (set of symptoms) and changing health issues,” he added.