Menopause treatment in practice: a GP guide to MHT / HRT

Professor James Brown — gynaecologist

Focus on reproductive and women’s health. Staff specialist with South Western Sydney Local Health District’s specialist menopause service. Senior lecturer in obstetrics and gynaecology at Western Sydney University. (Host introduction as heard on the recording; no invented details beyond that.)

Why offer MHT — indications

The speaker frames this as a quick practical guide: MHT (menopausal hormone therapy; also called HRT) is less complicated than it feels if you keep a few ground rules. Primary indication is alleviation of vasomotor symptoms — hot flushes, night sweats, heat intolerance, cold intolerance, and the related skin-crawling sensation called formication (“bugs on the skin”).

Also indicated for:

• Prevention of bone loss and fracture risk.
• Hypogonadism after early pathological menopause, primary ovarian insufficiency (POI), or surgical menopause (for example BRCA carrier status or endometriosis surgery removing ovaries).
• Less certain, but worthy of a trial: mood disorders (subtle), and sleep (cross-referenced to the morning sleep talk). Cardiovascular benefit under age 60 is framed as a possible happy accident if you prescribe for another reason — not a reason to start MHT by itself.

Who not to treat — contraindications and cautions

When — window of opportunity and perimenopause

The classic safety window discussed is starting within 10 years of menopause and under age 60. Common sense still matters: nobody “spontaneously combusts” at 60 and one hour. If the last period was only three or four years ago and the menopause profile fits with low background risk, commencement can still be reasonable. With transdermal estrogen there may be more flexibility into the early-to-mid 60s — but staying within the 10-year window is still the wiser default.

Investigations before starting

Example: a 54-year-old with hot flushes, last period 13 months ago, wanting MHT. Hormone panels are not required — especially in perimenopause, where FSH/estradiol swing day to day and cause confusing conversations. Midlife bloods are recommended but not mandatory.

• If you worry amenorrhoea has another cause: usual oligo-/amenorrhoea screen — prolactin, thyroid, FSH; consider ferritin and hCG when relevant.
• Menopause under 40 = primary ovarian insufficiency: consider genetic testing including FMR1 (fragile X premutation) — mainly for daughters’ future fertility counselling; not mandatory for menopause after 40.

Uterus rules — estrogen ± progesterone

• Cyclical progesterone while periods continue; continuous once periods have stopped.
• If periods are ultra-irregular (e.g. one every three months), continuous regimens are often reasonable for simplicity — you do not need a hard 12-month amenorrhoea rule before continuous use.

Delivery forms — oral, patch, gel

Three main groups discussed:

• Oral — estrogen alone or combined estrogen–progestogen.
• Patches — estrogen alone or combined; typically applied twice weekly.
• Estrogen gel — often paired with oral micronised progesterone (Prometrium).

Default starting preference is transdermal because it avoids the VTE worry of first-pass hepatic metabolism and has a more favourable cardiovascular profile. Oral remains a valid, predictable tool — especially for poor transdermal absorbers. A UK anecdote was cited: a woman on eight gel pumps with a non-therapeutic estradiol level. Hyper-absorbers also exist. Patches have variable availability; women may be strongly brand-loyal.

Starting doses and AMS equivalents

Do not start at a “baby” non-therapeutic dose and creep up from nothing. Commit to a reasonably therapeutic medium AMS-equivalent dose for most women, then titrate:

• Micronised progesterone: 100 mg daily continuous; 200 mg cyclical for about 12–14 days of the cycle. Try to time cyclical progesterone with the follicular phase rather than stacking progesterone on the luteal phase.
• Higher end discussed as roughly oral 2 mg estradiol ≈ 4 gel pumps ≈ 100 microgram patch — still within a “normal” operating range if clinically needed; serum levels matter more than the sticker dose if absorption is odd.
• Use the AMS dose-equivalence tables / product schema on the AMS website for PBS status and product tiers. Jean Hailes was also recommended as a resource.

Compliance, continuous progesterone, and products

• Do not follow the 25-of-28-day micronised progesterone gap for strictly postmenopausal continuous use just because that is how a study was labelled. Withdrawal bleeding from the gap worries everyone and wrecks compliance. Uninterrupted daily micronised progesterone is strongly preferred in practice.
• Patch brands (estrogen-only) mentioned in shortage context: Estradot, Estraderm, and other imported “estrogen” patches — women can be as brand-loyal as BTS fans; change kindly if stock forces a switch.
• Combined continuous products and oral body-identical options (e.g. Bijuve) were mentioned; PBS availability varies. Tibolone (Livial) remains a useful underused one-tablet option for milder vasomotor symptoms under 60, with estrogenic, progestogenic and androgenic receptor activity without being those hormones themselves.
• Breakthrough bleeding on micronised progesterone: consider stepping up progesterone, or moving to norethisterone (Primolut) / medroxyprogesterone (Provera), accepting more progestogenic side-effects (fluid, mood) but often better bleeding control.
• Respond to bleeding rather than over-anticipating it — variable absorption surprises you.

Review, dose titration, and levels

• Review at about three months. Month one is often odd (breast tenderness, bloating, tummy ache) as estrogen returns after a long gap — settle expectations.
• By months two to three you see the true effect. If vasomotor symptoms persist, increase estrogen (e.g. by about one pump-equivalent). If still failing after an increase, suspect poor absorption — switch gel ↔ patch, or move to oral if eligible.
• Serum estradiol ~200–300 (units as used in the talk) is a broad therapeutic ballpark for replacement — but if the level is “therapeutic” and symptoms persist, it may not be ongoing estrogen deficiency. Oral estrogen converts to estrone and is poorly reflected by serum estradiol assays.

Special situations and vaginal therapy

• Post-hysterectomy: estrogen only (unless endometriosis history — see above).
• Within about four months of the last menstrual period, consider contraception needs — Mirena can cover endometrium + contraception; other lower-clot oral options (e.g. Slinda) were mentioned in passing.
• POI: needs higher replacement doses to mitigate long-term low-estrogen risks — a whole lecture in itself.
• Vaginal therapy: usually start with standard vaginal estrogen; Ospemifene (Otter: “germors”) is an increasingly reasonable alternative among the choices discussed. Detail was brief at the end of the talk.

Take-home messages for clinic

1. Offer MHT for bothersome vasomotor symptoms (and bone / early hypogonadism indications) when contraindications are absent — do not invent CV prevention as the sole reason.
2. Know the short no-list (undiagnosed bleeding, hormone-sensitive cancer, active VTE, porphyria, active MI, severe active liver disease) and the milder cautions.
3. Prefer the 10-year / under-60 window; treat perimenopause when it looks like estrogen deficiency — do not force a year’s wait.
4. Skip unhelpful hormone panels in perimenopause; investigate amenorrhoea properly when something else is plausible; think FMR1 in POI under 40.
5. Uterus → estrogen + progesterone; no uterus → estrogen alone (add progesterone if endometriosis history).
6. Start at a sensible medium AMS-equivalent dose; default transdermal; keep oral for absorption failures; explain hepatic vs transdermal clot biology simply.
7. Continuous micronised progesterone daily in postmenopausal women — skip the 25/28 gap for compliance; switch gels/sachets/patches and progestogens when bleeding or adherence fails.
8. Review at three months; titrate; switch delivery if absorption looks wrong; use AMS / Jean Hailes rather than memorising every brand.

Dr Kotha · Gold Coast GP · honey theme · allcpd.drkotha.com/menopause-treatment/