Menopause Hormone Therapy 101: Understanding Your Options
Let's demystify Menopause Hormone Therapy (MHT)! If you're feeling overwhelmed by all the options and information out there, you're not alone. This guide will walk you through the basics of estrogen and progesterone therapy in a way that actually makes sense.
(We'll save vaginal estrogen and testosterone for another conversation—those deserve their own spotlight when we talk about vaginal health and libido!)
Meet the Dynamic Duo: Estrogen and Progesterone
Think of estrogen and progesterone as the cornerstones of MHT. Estrogen is definitely the main character here, and it's pretty impressive at what it does.
What Estrogen Can Do For You
Estrogen can be a game-changer. It can:
Reduce hot flashes and night sweats by up to 90% (and in clinical practice, some women see almost complete relief)
Dramatically improve sleep quality
Protect your bones from osteoporosis
Improve mood and reduce irritability
Help with skin and hair health to some extent
Take away joint and muscle pain
Not too shabby, right?
The Estrogen Family: Your Options
There are several types of estrogen available in Canada, and each has its own origin story:
Conjugated Equine Estrogen (CEE) is the OG of estrogen therapy. Yes, it's derived from the urine of pregnant horses—I know, not the most appealing fact! It's available in pill or cream form and was the estrogen used in the famous Women's Health Initiative clinical trial. To date, we have the most data about this form of estrogen.
Estradiol is derived from natural sources (mainly the Mexican yam or soy) and then synthesized into a molecule that's essentially a clone of the estrogen your ovaries produce. It can be delivered as a pill, patch, or gel—giving you flexibility in how you take it.
Ethinyl Estradiol is a synthetic form of estrogen (not a clone of your body's own estrogen but still very safe) that's found in oral contraceptive pills.
Estetrol is another body-identical form of estrogen found in the newer contraceptive pill called Nextstellis. This one is a clone of the type of estrogen your placenta produces during pregnancy.
Why You (Probably) Need Progesterone Too
Now let's talk about progesterone—estrogen's essential sidekick. Progesterone's main job is to protect your uterus against the effects of estrogen.
Here's why this matters: In the early days of hormone therapy, doctors prescribed estrogen alone. Over time, they noticed more and more women being diagnosed with uterine cancer. They realized that unopposed estrogen was causing the uterine lining (the endometrium) to become thicker and thicker, eventually developing cancerous cells.
The solution? Adding progesterone for anyone with a uterus allows the uterine lining to stay stable and shed when needed.
This is crucial to remember: If you have a uterus and are taking estrogen, you need a form of progesterone!
Your Progesterone Options
There are many types of progestin available:
Medroxyprogesterone Acetate was used in the Women's Health Initiative trials.
Norethindrone Acetate can be delivered in pill or patch form.
Micronized Prometrium is essentially a clone of the progesterone your ovaries produce. It comes in a capsule, and some generics are suspended in peanut oil, so YOU NEED TO HAVE BRAND NAME ONLY if you have a peanut allergy. It can also be used vaginally if needed. Other good news? It's now available in a combined capsule with estradiol called Bijuva, which does NOT contain peanut oil.
The Mirena IUD releases levonorgestrel (a progestin) directly to the uterus. While it's considered "off label" for MHT in some guidelines because it hasn't been formally included in all menopause treatment protocols, healthcare providers use it regularly with lots of good evidence showing it protects the uterine lining during perimenopause for UP TO 5 YEARS. It's included in the European Menopause Guidelines and is fantastic for heavy menstrual bleeding and contraception. (Important reminder: You can still become pregnant up until one year after your final menstrual period!).
Important note here: Mirena is effective for contraception for 8 years, but effective for endometrial protection for only 5 years, so you would have to change it or add some other form of progesterone from years 5-8 if needed!
The One Exception: Duavive
There's one notable exception to needing progesterone with estrogen therapy: a pill called Duavive.
Duavive is fascinating. It contains Conjugated Equine Estrogen plus something called a Selective Estrogen Receptor Modulator (SERM). The SERM essentially guides the estrogen away from places we don't need it (breast tissue and uterus) and toward places we definitely do need it (bone and brain). This prevents the uterine lining from thickening because it doesn't get exposed to the estrogen.
This is also a fabulous option for women with dense breasts, higher breast cancer risk, or who experience breast tenderness with estrogen.
When Can You Start MHT?
Here's something important: Technically, MHT is only "indicated" for women in menopause—meaning those who are no longer having any periods. However, expert consensus tells us that MHT is completely safe and very effective for women in perimenopause too. There's no need to wait for that final period to start treatment.
Tailoring Treatment to Your Stage
Treatment recommendations often depend on where you are in your perimenopause journey:
Early Perimenopause (still bleeding roughly once a month but experiencing symptoms like night sweats, hot flashes, disrupted sleep, and mood changes):
Consider cyclic therapy options:
A combined contraceptive pill without a long break (such as Lolo, Nextstellis, or continuous Alesse)
Estradiol daily with progesterone at 200mg for fourteen days of the month (two weeks on, two weeks off)
The Mirena IUD with estrogen added on (orally or through the skin)
This approach gives you more progesterone when it's most needed and less when your body is still producing enough on its own. Note that the contraceptive pill and Mirena both provide contraception, while cyclic progesterone does not—keep this in mind if contraception is relevant for you!
Late Perimenopause (you've gone 60 days without a period more than once):
You can start continuous combined MHT:
Nightly estrogen plus progesterone
Duavive
Bijuva
A combined patch
Estrogen alone if you've had a hysterectomy
The Bottom Line
Menopause Hormone Therapy isn't one-size-fits-all, and that's actually a good thing! With all these options, you and your healthcare provider can find the combination that works best for your body, your symptoms, and your lifestyle.
The key is understanding what each hormone does, why you might need both, and what delivery methods are available. Armed with this knowledge, you can have informed conversations with your doctor about what's right for you.
Important Disclaimer: This blog post is for educational purposes only and is not intended as individual medical advice. Menopause Hormone Therapy should be prescribed and monitored by a qualified healthcare provider who can assess your individual health history, risk factors, and needs. Always consult with your doctor before starting, stopping, or changing any hormone therapy regimen. What works for one person may not be appropriate for another.