Menopausal Hormone Therapy (MHT): A Comprehensive Guide to Your Options
What Is Menopausal Hormone Therapy (MHT)?
Menopausal Hormone Therapy–also called Hormone Replacement Therapy (HRT)--is the medical use of estrogen, progesterone, or a combination of both to treat symptoms caused by declining hormone levels in perimenopause and menopause. While the terms MHT and HRT are often used interchangeably, “MHT” is considered the more current, accurate medical term.
Benefits of Menopausal Hormone Therapy
MHT is one of the most effective treatments for menopausal symptoms and offers several whole-body benefits. MHT can improve sleep quality, reduce hot flashes and night sweats, support mood stability, enhance vaginal and urinary health, and protect long-term cardiovascular, bone, and metabolic health. When started within 10 years of menopause onset, it has been shown to reduce the risk of osteoporosis, fractures, and even all-cause mortality.
FDA-Approved Uses of Menopausal Hormone Therapy
MHT is FDA-approved for the treatment of several common menopause-related conditions:
Vasomotor symptoms such as hot flashes, night sweats, and sleep disruption
Genitourinary symptoms of menopause (GSM) including vaginal dryness, pain with intercourse, urinary frequency, and recurrent urinary tract infections
Bone loss including osteopenia and osteoporosis
Estrogen deficiency from premature ovarian insufficiency, surgical removal of the ovaries, radiation, or chemotherapy
Types of Hormone Therapy
The Role of Estrogen in Menopause Treatment
Estrogen is the primary hormone used in MHT because it directly addresses the root cause of most menopausal symptoms: declining estradiol levels. Estrogen therapy helps:
Reduce hot flashes and night sweats
Improve sleep quality
Support bone density
Enhance cognition
Improve vaginal moisture and elasticity
Reduce urinary symptoms and recurrent UTIs
The Role of Progesterone
If you have a uterus, progesterone must be included with any systemic estrogen replacement therapy to protect the uterine lining. Estrogen can cause the uterine lining to thicken (called endometrial hyperplasia), and progesterone opposes this effect. If you have had your uterus removed, progesterone is not necessary unless you are using it to manage specific symptoms.
Progesterone is also very helpful for sleep support, anxiety reduction, and mood regulation.
Bioidentical vs Synthetic Hormones
What Are Bioidentical Hormones?
Bioidentical hormones are structurally identical to the hormones naturally produced by the body. They are typically derived from plant sources and may be compounded or available at a regular pharmacy (FDA-approved).
Compounded Bioidentical Hormones
Compounded hormones are custom-made by compounding pharmacies. They allow for individualized doses, different delivery methods (creams, gels, troches, capsules), and personalize the formula to avoid additives one might be sensitive to.
Examples of common compounded options include:
BiEst (estradiol + estriol)
TriEst (estrone + estradiol + estriol)
Quality can vary from one compounding pharmacy to another, and rarely there are instances of contamination or inconsistent dosing, so it is important that your provider work with trustworthy and high-quality compounding pharmacies. Compounded medications are not covered by insurance.
FDA-Approved Bioidentical Hormones
These are standardized medications manufactured under FDA guidelines. These are typically covered by insurance and are available through regular pharmacies.
Examples:
Transdermal estradiol patches such as Vivelle-Dot, Dotti, Lyllana
Vaginal estradiol cream such as Estrace
Oral estrogen (also Estrace)
Micronized oral progesterone (Prometrium)
What About Synthetic Hormones?
Synthetic hormones do not share the exact molecular structure of the body’s natural hormones. They must be converted by the body into a usable form.
Examples include:
Medroxyprogesterone acetate (Provera)
Conjugated equine estrogens (Premarin)
While effective for some patients, many prefer bioidentical options due to their superior tolerability and metabolic profile.
Forms of Estrogen for Menopausal Hormone Therapy
Commercially Available Estrogen Options
Oral Estrogen: Convenient but undergoes first-pass liver metabolism, which can slightly increase the risk of clotting, raise triglycerides, and affect blood pressure.
Estrogen Patch: A transdermal option changed twice weekly. This is the form I most commonly prescribe because it's easy, covered by insurance, and has a much lower clotting risk than oral estrogen.
Vaginal Ring: Inserted into the vagina and continuously delivers estrogen for three months.
Vaginal Creams/Suppositories: Low-dose, local estrogen that improves vaginal dryness, pain with intercourse, and recurrent UTIs. These can be safely combined with systemic estrogen.
Compounded Estrogen Options
Transdermal creams (customized dosing, can be combined with progesterone)
Troches (dissolve in the cheek for rapid absorption)
Compounded oral or adhesive options
I do not use estrogen injections or pellets, as they cannot be adjusted easily, often lead to overdosing, and carry higher risk.
Progesterone Options in MHT
Progesterone is available as:
Oral micronized progesterone
Topical creams
Vaginal gels
Progestin-containing IUDs
Patch formulations
Important: Topical creams do not provide adequate uterine protection when used with systemic estrogen. I use oral micronized progesterone or a progestin-containing IUD (such as Mirena IUD) to protect against endometrial hyperplasia
Risks & Side Effects of Menopausal Hormone Therapy
Understanding the Updated Safety Profile
Since the 2002 Women’s Health Initiative study, there has been the pervasive idea that MHT puts you at high risk of developing blood clots and breast cancer. This black box warning was recently removed from estrogen replacement therapy (thankfully!) as MHT is not only quite safe for most patients, but extremely effective at treating symptoms and offers significant health benefits.
Potential Risks
Gallstones
Pancreatitis
(Oral estrogen only): mild increased clotting risk
Common Side Effects
These are often dose-related and improve as time passes:
Breast tenderness
Irregular uterine bleeding (evaluation needed if persistent >6 months)
Headaches
Bloating
Nausea
Mood changes
Dizziness
Swelling
Who Is a Good Candidate for MHT?
You may be a good candidate for hormone therapy if you:
Have bothersome symptoms
Are within 10 years of your final menstrual period
Are seeking long-term protection for bone and cardiovascular health
Even if more than 10 years have passed, low-dose MHT may still be an option.
Who Should NOT Use Estrogen Therapy?
Estrogen replacement therapy is typically not recommended for those with:
A recent history of blood clots, stroke, or heart attack
A personal history of estrogen- or progesterone-sensitive cancers
Unexplained vaginal bleeding
Active liver disease
Known or suspected pregnancy
Known allergy to MHT components (though compounded medications may be an option)
Note: vaginal estrogen is often safe to use even with a history of these conditions, but of course discuss with your provider.
My Approach to Hormone Therapy
In my practice, I almost exclusively prescribe bioidentical hormones. I usually start with FDA-approved bioidentical hormone therapy as these are covered by insurance for most patients.
I do frequently work with compounding pharmacies for MHT. Compounded formulations are especially useful when:
A patient has allergies or sensitivities
An in-between or lower dose is needed
For example, micronized progesterone is available in 100 mg and 200 mg strengths commercially, but some patients benefit from custom doses.
A specific delivery method is preferred
When starting MHT, I begin with the lowest effective dose based on your symptoms and goals. Most people will experience improvement quickly, but maximum benefit takes about 3–4 weeks. We follow up at the four-week mark to evaluate symptoms and adjust the plan if needed.
Learn more about working with me here.
Ready to Feel Like Yourself Again?
Menopause doesn’t have to be something you just endure. With the right support and a personalized hormone therapy plan, it’s absolutely possible to sleep better, think more clearly, and feel more like you again.
If you’re interested in understanding your options or starting a personalized hormone plan, I’m here to support you.
Click below to schedule a virtual visit and get a personalized treatment plan tailored to your body, your symptoms, and your goals.
Disclaimer: The information in this article is intended for general informational and educational purposes only. It is not intended to diagnose, treat, cure, or prevent any condition, nor should it replace guidance from a qualified healthcare professional. Please speak with your provider about your individual health questions and before making any changes to your care plan.