Hormone therapy (HT)

Hormone therapy (HT) is a system of hormone replacements or treatments for various symptoms using synthetic forms of oestrogen and progesterone (called progestin).

The most common reason for hormone therapy is to manage symptoms associated with the onset of menopause like hot flashes, insomnia, and headaches, and postmenopausal declines in oestrogen.

A woman is likely to only be on hormone therapy for a few years, and hormone therapy is typically not advised for long periods of time. Women are almost always given continuous oestrogen, however progestin (synthetic progesterone) use depends on when her last period was.

Perimenopausal women are cycled with oral doses or a patch containing hormones (transdermal), and will have cyclic bleeding. Taking both hormones at once manages the increased risk presented by unopposed oestrogen.

Post-menopausal women will receive continuous low-dose progestins to avoid a withdrawal bleed. The endometrium eventually becomes very thin and nonfunctioning.

Anyone who has had a hysterectomy may be taking continuous oestrogens.

Hormone therapy or hormone replacement therapy?

Hormone replacement therapy (HRT) is an outdated term, replaced with just hormone therapy (HT).

What does HT do?

Hormone therapy bumps up your hormone levels (oestrogen, progestin) either temporarily, cyclically, or on an ongoing basis to help stop symptoms of menopause occurring, such as hot flushes and sleep issues.

Hormone therapy can also help combat osteoporosis, since oestrogen helps keep calcium in bones. Hormone therapy can be high or low dose. When progestin is combined with oestrogen, it protects against endometrial cancer.

Endometrial cancer can develop with oestrogen-only therapy. If a woman does not have a uterus, HT is not required. Monthly withdrawal bleeding may occur if progestin is used cyclically.

Withdrawal bleeding is not a true period, but the result of hormone withdrawal on the endometrium.

What are the risks of hormone therapy?

Hormone therapy does not come without risks, but the risk is usually offset by when you start hormone treatments and how long these treatments are used for.

Short-term hormone therapy early in menopause is associated with less risks than starting later in menopause. Not all women have the same level of risk.

Hormone therapy may increase the risk of:

Due to these risks, some recommendations are in place for hormone therapy:

  • Only use hormone treatments short-term for menopausal symptoms
  • Use only the lowest effective dose for the shortest time possible (symptoms usually pass and disappear over time)
  • Use osteoporosis prevention and treatment where applicable
  • Long-term hormone therapy should only be used in women with a high risk of osteoporosis because the risk of bone loss is worse than other risks
  • Consider all your options and compare risks and benefits

Do not use hormone therapy if you:

  • Might be pregnant
  • Have a personal history of breast, ovarian or certain endometrial cancers
  • Have a personal history of pulmonary embolism, deep vein thrombosis, heart attack or stroke
  • Have undiagnosed vaginal bleeding from unknown causes
  • Have liver disease (though some liver-sparing oestrogens may be used, like the transdermal patch or vaginal creams)

How well does hormone therapy work?

There is plenty of evidence that increased oestrogen levels can reduce the severity and frequency of hot flushes, improve mood and sleep problems, and maintain the vaginal tissue.

Increases in the collagen in skin and tissue have been observed. Osteoporosis is slowed, and tooth loss and gum disease risk can be reduced.

Side-effects of oestrogen-based hormone therapy

  • Irregular vaginal bleeding
  • Headaches
  • Nausea
  • Discharge
  • Fluid retention
  • Weight gain
  • Tender breasts
  • Skin pigmentation
  • Gallstones
  • Possible worsening of endometriosis or uterine fibroids
  • Skin irritation with transdermal patches
  • Side-effects may abate after a few weeks of use

Side-effects of progestin-based hormone therapy

  • Mood changes – anxiety, irritability, depression
  • Headaches
  • Breast pain or tenderness
  • Abdmonal pain or bloating
  • Dizzy
  • Drowsy
  • Diarrhoea
  • Discharge

Cyclic progestin (taken 10-14 days per month) can cause PMS-like symptoms (bloating, cramping, breast tenderness, nausea, depression) and monthly withdrawal bleeding.

Use of the Mirena hormonal IUD can alleviate some of the oral-progestin-based symptoms in some women.

Oestrogen and progestin combined pills/tablets

  • Conjugated oestrogens/medroxyprogesterone under the brand names Premphase or Prempro (combined pill/tablet)
  • Oestradiol/norethindrone under the brand name Activella (combined pill/tablet)
  • Oestradiol/norethindrone acetate under brand CombiPatch – skin patch (transdermal)
  • Medroxyprogesterone under brand name Provera (oral progestin in a pill or tablet + an oestrogen-only preparation)
  • Micronised progesterone under brand name Prometrium (oral progestin in a pill or tablet + an oestrogen-only preparation)
  • Norethindrone under brand names Micronor or Nor-QD ((oral progestin in a pill or tablet + an oestrogen-only preparation)
  • Norethindrone acetate under brand name Aygestin (oral progestin in a pill or tablet + an oestrogen-only preparation)
  • Levonorgestrel IUD under brand name Mirena (intrauterine device)

What are natural alternatives to hormone therapy?

There are a handful of treatments that a naturopath or herbalist might use to combat unpleasant menopausal symptoms. The treatments will vary depending on what symptoms are present and which stage the woman is at.

Natural treatments for perimenopausal symptoms

Perimenopausal premenstrual syndrome (PMS) may be treated with herbal medicines that work to manage the uncomfortable effects of fluctuating hormones.

Hormonal modulators, nervines, adrenal adaptogens and bitters may be used. Supplements that can be useful include magnesium, vitamin B6, and evening primrose oil, while adopting a low glycaemic-index diet may be beneficial.

Natural treatments for menopausal symptoms

As oestrogen declines, different symptoms appear than during perimenopause, so treatments are adapted as necessary. Herbal medicine may be used to modulate hormones, and nervines given.

Phyto-oestrogens can be added to the diet, along with extra calcium, magnesium and vitamin E.

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Jessica Lloyd - Vulvovaginal Specialist Naturopathic Practitioner, BHSc(N)

Jessica is a degree-qualified naturopath (BHSc) specialising in vulvovaginal health and disease, based in Melbourne, Australia.

Jessica is the owner and lead naturopath of My Vagina, and is a member of the:

  • International Society for the Study of Vulvovaginal Disease (ISSVD)
  • International Society for the Study of Women's Sexual Health (ISSWSH)
  • National Vulvodynia Association (NVA) Australia
  • New Zealand Vulvovaginal Society (ANZVS)
  • Australian Traditional Medicine Society (ATMS)