What MHT does

MHT replaces the estrogen that the ovaries are no longer producing. For women who still have a uterus, a progestogen is added to protect the uterine lining. Women who have had a hysterectomy take estrogen alone.

What MHT treats

  • Vasomotor symptoms (hot flashes and night sweats) — the most effective treatment available
  • Sleep disturbance related to menopause
  • Urogenital symptoms (vaginal dryness, bladder symptoms) — local vaginal therapy is particularly effective
  • Prevention of bone loss and fractures — reduces fracture risk regardless of baseline bone density
  • Menopause-associated mood changes (though not clinical depression)

Forms of estrogen

Oral estrogen

Convenient and reliably absorbed. Options include conjugated equine estrogens (CEE), estradiol valerate, and micronized estradiol. Oral estrogen is processed through the liver (“first pass”), which is the source of most potential side effects, including a small increase in blood clot risk.

Transdermal estrogen (patches, gels, sprays)

Estradiol absorbed through the skin bypasses liver metabolism. This is clinically significant: transdermal estradiol does NOT increase blood clot risk at standard doses and has neutral effects on blood pressure and triglycerides. Generally preferred for women who smoke, are overweight, have diabetes, a history of blood clots, or elevated triglycerides.

Vaginal estrogen

Low-dose estrogen applied locally is highly effective for vaginal and bladder symptoms with minimal systemic absorption. It does not require a progestogen and is safe for long-term use. Many women who cannot use systemic MHT can safely use vaginal estrogen.

Other hormonal options

Tibolone

A synthetic steroid metabolized to produce estrogenic, progestogenic, and mild androgenic effects. No separate progestogen required. May improve sexual desire. Should not be started until 12 months after the last period. (Not available in the United States.)

Estrogen + bazedoxifene

A fixed-dose combination where bazedoxifene (a SERM) protects the uterine lining — no separate progestogen needed. Effective for hot flashes. The estrogen dose cannot be adjusted.

Ospemifene

An oral SERM approved for vulvovaginal atrophy symptoms. Acts like estrogen in vaginal tissue, improving dryness and reducing pain with intercourse. About 10% of users experience hot flashes as a side effect.

Testosterone for women

The only evidence-based indication is loss of sexual desire causing personal distress. Transdermal testosterone at female-appropriate doses can improve desire, arousal, orgasm, and satisfaction. Not a standard part of MHT.

Cyclical vs. continuous-combined MHT

Cyclical (sequential) MHT: Estrogen taken every day; progestogen added for 12–14 days per month. Results in a predictable withdrawal bleed. Often used during perimenopause and early postmenopause.

Continuous-combined MHT: Both estrogen and progestogen taken every day. In 90% of women, results in no bleeding within 12 months. Some breakthrough bleeding in the first 3 months is normal. Best suited to clearly postmenopausal women.

Sources