Your Complete (Canadian) Guide to MHT Options: Patches, Pills, and Everything In Between
Ready to dive into the nitty-gritty of Menopause Hormone Therapy options? Let's break down the most popular forms of MHT so you can have an informed conversation with your healthcare provider about what might work best for you.
Transdermal Options: Patches and Gels
Estrogen Patches: The Set-It-and-Forget-It Option
Estrogen patches deliver a constant, low dose of estradiol—the body-identical form of estrogen. They're tiny, clear stickers that you apply to clean, dry skin on your upper buttocks, upper thigh, or lower abdomen.
Estradot is changed twice a week and comes in 25, 37.5, 50, 75, and 100 microgram doses. The beauty of Estradot? It can be cut in half if needed, and you can even place two patches together for flexibility if the pharmacy runs out of your specific dose.
Climara is changed once per week and comes in 25, 50, and 75 microgram doses in Canada. It's bigger than Estradot and cannot be cut. Some women find it starts coming off at the edges as the end of the week approaches, while others absolutely love it. You can always try one and switch if it's not working for you!
Pro Tips for Patch Success
These patches stay on remarkably well through sweat, showering, swimming, and daily life. But if you're having trouble getting them to stick:
Clean the area with an alcohol wipe and let it dry completely
Press the patch firmly in place and hold for 10-20 seconds
Run a warm hairdryer over the patch for about 20 seconds
If the patch leaves residue after removal, try peeling it off slowly instead of ripping it quickly, then remove any leftover adhesive with oil-based makeup remover or baby oil.
Estrogen Gels: A Discreet Alternative
If patches aren't your thing, there's gel! While there's a pump version called Estrogel (total daily dose 1-4 pumps per day), many providers prefer Divigel instead. Divigel comes in little sachets with the exact dose of estradiol in each one—no guessing involved.
You apply it each night to the inner thigh in a thin layer, let it dry for about two to three minutes, and you're done. Divigel comes in 25, 50, and 100 microgram doses. Need 75 micrograms? Simply combine a 25 and a 50 together.
The Estrogel pump is a lower concentration than divigel, and because it is applied over the entire arm, it does not absorb as well, therefore higher doses are typically required to achieve the same effect as the equivalent dose of Divigel.
Why Transdermal is Special
Topical or transdermal estradiol has some serious advantages:
No increased blood clot risk. It goes directly to your bloodstream without passing through your liver first, which means it doesn't interfere with blood clotting factors the way oral estrogen can. (We'll talk more about that risk when we discuss oral options.) At baseline without any MHT, your risk of a blood clot is about one-2 in a thousand per year (for an average risk woman). Transdermal estrogen doesn't increase that risk especially at lower doses—though it doesn't decrease it either, so you'd still need to be careful during long flights, long car rides, or after surgery when you're immobilized.
Lower doses work better. Because transdermal estrogen avoids the digestive system, more of it is available for the estrogen receptors throughout your body. It doesn't get metabolized by the liver first, so you can use much lower doses for the same effect.
Adding Progesterone: The Essential Partner
Remember the golden rule: If you have a uterus, you need progesterone with your estrogen.
Prometrium: The Natural Choice
Prometrium is the most commonly prescribed progesterone option, and for good reason. It's natural progesterone (micronized, to be exact) and comes with several advantages:
No demonstrated increased breast cancer risk, according to available data
Fewer side effects compared to synthetic progestogens
One delightful side effect: Sedation, which is fantastic for sleep maintenance in most women
As one patient eloquently put it: "If progesterone were a person, I would hug it." You'll want to take it at bedtime to take advantage of that sleepy effect.
Dosing Details
For estradiol doses up to and including 50 micrograms: 100mg of Prometrium
For higher doses or cyclic use (two weeks on, two weeks off): 200mg of Prometrium
Important Notes About Prometrium
The capsules are round and a bit unusual-looking, so they may not be ideal if you have trouble swallowing pills. Some of the generic versions are suspended in peanut oil, so you must request brand name Prometrium if you have a peanut allergy!
Here's a neat trick: If you experience too much sedation or other side effects, you can insert Prometrium high in the vagina at bedtime instead of taking it orally. It will still provide good protection for your uterine lining!
The Combined Patch Option
There is one combined patch worth mentioning that includes both estrogen and a synthetic progestin. It's changed twice a week, just like Estradot.
The downsides? It tends to cause quite a bit of spotting—not something you want after menopause. However, it's a good consideration for women who can't swallow pills, have side effects with Prometrium, or have a peanut allergy. Some patients absolutely love it!
Oral Combination Options: All-in-One Pills
Bijuva: Body-Identical Hormones in One Pill
Bijuva contains oral estradiol and Prometrium—the only oral option with both body-identical forms of estrogen and progesterone. The oral estrogen dose is 1 milligram (equivalent to 50 micrograms topically), and it includes 100 milligrams of progesterone to protect your uterine lining.
It's taken at bedtime, is smaller than Prometrium alone, and does not contain peanut oil—making it a great alternative for those with peanut allergies.
Duavive: The Breast-Friendly Option
We talked about Duavive in last week’s blog, but it deserves another mention. It's a fantastic option for women with:
Dense breasts
Higher risk of breast cancer
Breakthrough spotting
Higher risk of uterine cancer
Duavive is associated with less breast density and less breakthrough bleeding. It contains the same estrogen used in the Women's Health Initiative trial—conjugated equine estrogen, which is naturally derived (from pregnant horse urine).
Tibolone (Tibella): The Triple-Action Option
Tibolone is a synthetic combination tablet that's really unique. It acts as an estrogen, a progestogen, AND a testosterone derivative all in one pill, although it’s not technically considered a hormone tablet.
Benefits include:
Small amount of weight loss
Improved libido
All the other benefits of standard MHT options
Don't let "synthetic" scare you—it just means the chemical molecule isn't a clone of our natural hormones, but it works in much the same way and affects the same receptors.
The "Off-Label" Option: Mirena IUD
The Mirena IUD deserves special recognition as an excellent "off-label" option for MHT. It sits in your uterus and releases levonorgestrel (a progestin) directly to the uterine lining, providing excellent protection when paired with estrogen therapy.
Many providers use it regularly with great results, and it's included in the European Menopause Guidelines. Bonus: It's also fantastic for heavy menstrual bleeding and contraception!
One important caveat: Mirena may be used for up to 8 years for contraception, however it provides adequate endometrial protection for only 5 years. This means that if Mirena is your only progestin component for MHT, you need to change it after 5 years or consider adding some oral prometrium to your regimen.
Finding Your Perfect Fit
This isn't an exhaustive list of all MHT options—think of it as a starting point to help you understand where you might fit based on your health history and personal preferences.
Keep in mind that all options may not be suitable for all women. Your healthcare provider will discuss potential risks, benefits, and any contraindications specific to your situation.
Do You Need Hormone Level Testing?
Here's something that confuses many women: No, you typically don't need your hormone levels checked while taking MHT.
Why? Because your ovaries (when they were active) gave off much higher levels of estradiol and progesterone than MHT products do. MHT typically delivers about one-eighth to half of the normal levels we'd expect after menopause.
Since these products are tightly regulated and we know exactly how much hormone is in each batch, we determine the right dose based on your symptom control. How your estrogen receptors react to the dose is individual to you, and there's no blood test that can determine that. Your experience is the best guide!
The Bottom Line
From patches to pills, gels to IUDs, there's truly an MHT option for almost every woman and every lifestyle. The key is finding what works for YOUR body, YOUR symptoms, and YOUR daily routine.
Work with your healthcare provider to experiment (if needed) and find your perfect fit. What works beautifully for your friend might not be right for you—and that's completely normal!
Important Disclaimer: This blog post is for educational purposes only and is not intended as individual medical advice. The information provided here is meant to help you have informed discussions with your healthcare provider, not to replace professional medical guidance. Menopause Hormone Therapy should be prescribed and monitored by a qualified healthcare provider who can assess your individual health history, current medications, risk factors, and specific needs. What's appropriate for one person may not be suitable for another. Always consult with your doctor before starting, stopping, or changing any hormone therapy regimen.