Menopausal Hormone Therapy (MHT)

Menopausal hormone therapy (MHT) is meant for women whose everyday life is being disrupted by the hormonal changes of perimenopause and menopause. The clearest reason to use it is moderate to severe vasomotor symptoms: hot flashes and night sweats that interrupt sleep, concentration or work. It is also appropriate for genitourinary symptoms such as vaginal dryness and painful sex, and it is the most effective way to prevent bone loss in women who start early and are at risk of osteoporosis.

Guidance from the Menopause Society and other major bodies is that for healthy women under 60, or within ten years of their final period, the benefits of treating bothersome symptoms generally outweigh the risks. This "timing hypothesis" matters: the same therapy that has a favourable profile at 52 can have a different one at 70, so age and years since menopause are central to any prescribing decision.

Estrogen is the hormone that relieves symptoms. If you still have a uterus, though, estrogen on its own stimulates the womb lining and can raise the risk of endometrial overgrowth. A progestogen is added to keep the lining thin and protected. Micronised progesterone, chemically identical to the hormone your body makes, is generally preferred to synthetic progestins in current guidance, and many women find that taking it at bedtime also helps sleep.

If you have had a hysterectomy, estrogen alone is normally used and no progestogen is needed. Some women also use a levonorgestrel intrauterine device or a combined estrogen-progestin product. The right regimen depends on your uterus, your bleeding pattern, your preferences and your risk factors, which is exactly what the clinician reviewing your intake should work through with you.

Estrogen can be swallowed as a pill, worn as a patch, applied as a gel, spray or cream, or placed in the vagina for local symptoms. Oral estrogen passes through the liver first, which modestly increases clotting-factor production. Transdermal estrogen (patch, gel, spray) bypasses the liver, and observational data consistently show a lower risk of venous blood clots, so it is often the first choice for women with higher cardiovascular risk, migraines or raised triglycerides.

For symptoms confined to the vagina and bladder, low-dose vaginal estrogen treats the tissue directly with minimal absorption into the bloodstream. It can be used alone or alongside systemic therapy. Our guides to transdermal estrogen patches and bioidentical hormone therapy go deeper on each route.

Most women notice fewer hot flashes within two to four weeks, with the fullest benefit by around three months, and sleep and mood often improve alongside. Early side effects such as breast tenderness, bloating or irregular spotting are common in the first weeks and usually settle as your body adjusts. Persistent heavy bleeding, or any bleeding after your periods have fully stopped while on a continuous regimen, should be reported to your clinician, not waited out.

A good provider will check in after the first few weeks and again around three months to adjust the dose or route. The goal is the lowest dose that controls your symptoms, reviewed at least yearly, rather than a fixed prescription that never changes.

MHT is not right for everyone. It is generally avoided with a history of breast cancer or other estrogen-sensitive cancers, a previous blood clot or stroke, active liver disease, or unexplained vaginal bleeding that has not been investigated. In women with a uterus, combined therapy is linked to a small increase in breast cancer risk with longer use, while the signal for estrogen alone is weaker. The absolute numbers are small for most healthy women, but they are real, and they are the reason treatment is individualised and reviewed over time.

Reputable telehealth platforms screen for these conditions at intake and may ask for recent blood pressure readings, mammogram history or lab work before prescribing. Treat that screening as a sign of a careful provider, not an obstacle.

Online providers have made MHT far easier to begin, with intake forms, asynchronous or video consultations and prescriptions shipped to your door. When comparing platforms, check whether the clinicians specialise in menopause, which hormone formulations are offered, whether follow-up is included in the price and how lab work is handled. Our menopause provider rankings score these factors, and our guide to buying HRT online explains how to spot a legitimate prescriber.