Update on Hormonal Treatment of Menopause (Mason, 3/18/26)

A recording of this presentation is available HERE.

Many thanks to Dr. Antoinette Mason for an important presentation on Hormonal Treatment of Menopause. Dr. Mason is a graduate of our residency program and is also a graduate of our integrative medicine fellowship.

Her stated goal of the presentation: to empower clinicians to use menopausal hormonal therapy (MHT) 

Before 2002, menopausal patients regularly received MHT. After 2002, when the Women's Health Initiative (WHI) was stopped early due to concerns regarding increased rates of breast cancer, blood clots, dementia, CVD and more. This led to a lot of fear and an abrupt change in practice-- as a result, most clinicians have been trained to avoid hormones in menopause.

Over the past 15 years, there has been lots of re-evaluation of the data. Also formulations of hormones used today are not the same as those used in the WHI. Timing matters, age of start matters. 

We are now reckoning with fear, beliefs, lack of evidence, training. . .many of our leading organizations (Menopause Society, ACOG, Endocrine Society) have guidelines that confirm that MHT is safe and appropriate for many populations. 

bio-identical means "same compounds made by the ovaries" (estradiol  (E2) + micronized progesterone), but there are LOT of different formulations of these as well.

Risks of MHT:

• blood clots: associated with oral estrogen (including OCPs, conjugated equine estrogen, oral estradiol). Oral estradiol safer than OCPs, 3-4x risk OCP vs. oral estradiol. But transdermal (patches, gels, cream) do NOT increase risk of blood clots. 
• gallbladder disease: cholelithiasis, cholecystitis, low but increased
• endometrial hyperplasia/cancer: unopposed estrogen therapy (need to give estrogen therapy)
• breast cancer: WHI showed small increase in rate of breast cancer, but estrogen alone actually reduced breast cancer. Risk for breast cancer seems driven by progestin >5 years (when use mircorinized progesterone NO increased risk of breast cancer but no good RCTs). Safest approach: use MHT<5 years. We may never have RCT with clear data. 

Hormonal Cheat Sheet:

FDA approved indications for MHT:

• vasomotor symptoms: hot flashes, night sweats
• genitourinary syndrome of menopause: urinary/vaginal symptoms, dyspareunia
• prevention of osteoporosis in people who are high risk (e.g. family hx, comorbidities), do NOT treat osteoporosis but does prevent fractures
• treatment of early ovarian failure or surgical menopause

Additional benefits (not FDA approved)

• musculoskeletal syndrome of menopause: changes in joints, connective tissues, muscles (pain, stiffness, new joint pain that is NOT arthritis)
• mood/cognitive changes/sleep
• quality of life
• miscellaneous short and long impacts: fractures, colon cancer, breast cancer (estrogen alone), diabetes, improvement in insulin resistance, better blood glucose control for people with DM, LDL reduction (transdermal estradiol), reduced CVD, dementia (mixed studies, ?vascular)

Timing hypothesis: earlier is better (age <60 years of age or <10 years since menopause onset)

How to rx MHT:

• use bio-identical hormones
• use transdermal estrogen whenever possible
• start early, use lowest effective dose (titrate to symptom control)

Absolute contraindications: current breast cancer or hx of breast/endometrial cancer, current or hx VTE, severe liver disease, pregnancy, uncontrolled severe hypertension (get BP under control first)

Assess risk: If high risk for VTE, do NOT use oral estrogen. If high risk CVD, look at lipids, A1c, recommend yearly mammogram, osteoporosis risk

1. Do they need birth control or do they not want to ovulate? (if yes, consider IUD/OCPs)
2. Do they have a uterus? (if yes, they need some progesterone)
3. Are they having regular cycles? (if yes, luteal dosing of progesterone, if no, can use continuous progesterone)

Progesterone decline

For most people in menopause, progesterone starts to decline and estrogen gets chaotic. Eventually post-menopause, both get low but in the transition it's very unpredictable. A lot of people have symptoms associated with low progesterone state initially. Most common: anxiety, insomnia, shortening cycles, headaches. Can just use micronized progesterone alone in early menopause symptoms: e.g. start with 100mg orally or vaginally (same capsule) just 2 weeks after ovulation (in luteal phase).  . .Can later increase dose or add estradiol. If cycles are irregular and unpredictable, can use continuous progesterone at night. Vaginal progesterone can be less sedating.

LOOP events

LOOP events (luteal out of phase event): ovulatory event, and then in the luteal phase (week or two after ovulation, you get another ovulation>> can cause anemia, other issues for people).

OCP can work, but for those who don't' want OCPs, can use progesterone to stabilize the endometrium and try to reduce bleeding. Start 100mg QHS (lowest dose), can increase to 200-300mg to stabilize bleeding. Adding estradiol can help (oral helps more than transdermal but have to balance safety and benefit). Don't forget birth control!

Common Progesterone side effects: constipation (fiber/magnesium/water), morning grogginess (can try earlier in the evening, switch to vaginal formulation)

Estrogen Decline

estrogen decline symptoms: vaginal symptoms, hot flashes, irregular period

Can start estradiol (start with lowest patch>> twice weekly better than once weekly, smaller, adhesive less sticky). Currently supply chain issue, harder to get right now

Follow up 4-8 weeks because hot flashes should respond quickly>> if they don't get better, need more estrogen

Vaginal Estrogen 

Vaginal estrogen should be used liberally for genito-urinary symptoms of menopause. Vaginal estrogen can be used SAFELY for almost everyone, including post partum. Can decrease UTIs in elders. Cheap, easy, effective tool. Note there are TWO vaginal rings (one rx'd for local therapy, one for systemic therapy. Make sure you know which you are rx'ing)

Testosterone: Low dose topical testosterone VERY low dose for sexual dysfunction of menopause (1/10th male dose). Always optimize estrogen and progesterone first to see if symptoms improve. Do not put testosterone gel on clitoris.