Menopause hormone therapy - also known as hormone replacement therapy (HRT) can be helpful to alleviate both perimenopausal and menopausal symptoms, improve quality of life, improve sleep, relationships and more.

What is perimenopause?

Perimenopause is the first stage of menopause. It is the time of life approaching and after menopause when your ovaries are slowly starting to make less estrogen and progesterone. You might have some perimenopausal symptoms during this time. It can occur 4-10 years prior to menoause which usually happens between the ages of 45 and 55 years.

Your periods may still be regular, but you may notice them becoming lighter or heavier than before. You may also develop cyclical symptoms such as migraine, anxiety, mood changes, vaginal dryness - especially during the luteal phase ie the 2 weeks prior to your period. Eventually the periods do become irregular and the associated physical and cognitive symptoms can occur across the entire month.

What is menopause?

Menopause is the time in a woman’s life when her period stops. It usually happens around age 51, but it can happen earlier or later. Once you’ve gone 12 months since your final menstrual period, you’re considered to be post-menopausal. It is in the few years before and after the final period when hot flashes are most common.

Hormone Replacement Therapy Options

While the symptoms of menopause may be mild and managed with lifestyle changes such as; a eating whole foods, stress management or sleep support for some women, others experience severe and debilitating symptoms.

Hormone therapy is the most effective treatment available for menopausal symptoms, especially for moderate to severe symptoms. It involves using estrogen (either alone or with a progestogen). Where menopause symptoms negatively affect your quality of life, menopause hormonal therapy can be life-changing.

The types of Menopause Hormone Therapy include:

• Estrogen alone (via pill, patch, gel or spray) - this typically is natural estradiol, chemically known as 17 beta-oestradiol.
• Estrogen (as above) + progestogen (natural progesterone or a synthetic progestin such as provera or norethisterone)

Some women find their perimenopause symptoms are best treated with hormonal contraception such as

• Combined oral contraception 
• Progestin-only contraceptive pill (mini pill)
• or Mirena (with or without estrogen)

What Are The Types of Hormone Replacement Therapy Regimes?

There are different ways to use HRT.

Cyclical (or Sequential) HRT more closely mimics the menstrual cycle, with estrogen used during the entire cycle, but progestogen only used during the luteal phase (12-14 days). 

Continuous HRT is used once menstrual cycles are no longer occuring and provides continuous estrogen and progestogen.

Cyclical (Sequential) HRT

• Who It’s For: Women who are perimenopausal and still having regular or irregular periods.
• How It Works:
  • Estrogen: Used continuously (daily if gel or pill, twice weekly patch change for patch) to manage symptoms like hot flashes, mood swings, and vaginal dryness.
  • Progestogen: Added for 12–14 days of each cycle to protect the uterine lining from overgrowth caused by estrogen.
  • Results in a monthly withdrawal bleed, similar to a period.

Benefits of Cyclical HRT:

1. Mimics Natural Cycles: Works in harmony with your body's existing hormonal rhythm during perimenopause.
2. Uterine Protection: Progestogen protects the uterine lining, reducing the risk of endometrial hyperplasia (an over-thickened lining).
3. Symptom Relief: Reduces perimenopausal symptoms while accommodating natural hormonal fluctuations.

Continuous Combined HRT

• Who It’s For: Women with long menstural cycles or who are postmenopausal (no period for 12 months or more).
• How It Works:
  • Estrogen and Progestogen: Both are taken daily without a break, maintaining consistent hormone levels.
  • This does not cause monthly bleeds.

Benefits of Continuous Combined HRT:

1. No Monthly Bleeding: Ideal for postmenopausal women who want to avoid regular bleeding.
2. Steady Hormonal Support: Provides consistent symptom relief without the hormonal fluctuations of a cycle.
3. Simplified Regimen: Easier to manage with no need to track cycles or take hormones intermittently.

Choosing the Right Regimen

• Cyclical Regimens: Best for women in the transitional phase of menopause who still have some ovarian activity. It helps manage symptoms while aligning with natural cycles.
• Continuous Regimens: Recommended for postmenopausal women or those transitioning from cyclical HRT after menopause is confirmed. It offers convenience and avoids the monthly bleed.

See our Guide Below To Determine The Best Type Of Menopause Hormone Therapy For You

Option 1: I Am Having Regular Periods

• HRT Options:
  • Cyclical HRT: Mimics your natural cycle.
    • How It Works: Estrogen is taken daily, with progestogen added for 10–14 days per month to protect the uterine lining.
    • What to Expect: A monthly withdrawal bleed, similar to a period.
  • Contraceptive Options for HRT + Pregnancy Prevention:
    • Combined Oral Contraceptive Pill: Provides contraception while offering some symptom relief. Suitable for women <50 with no contraindications.
    • Mini-Pill (Progestogen-only Pill): Can be combined with estrogen for HRT, especially if estrogen-only symptom relief is needed.
    • Mirena IUD: Provides contraception and localized progestogen for uterine protection. Estrogen can be added separately (patch, pill, or gel).

Option 2: My Periods Are Irregular (>45 Days Apart) or I Have No Periods for >1 Year (Postmenopause)

• HRT Option: Consider continuous combined HRT (estrogen and progestogen daily) if postmenopausal.
• What to Expect:
  • Estrogen relieves symptoms like hot flashes and improves bone health.
  • Progestogen protects the uterine lining if you still have a uterus.
  • No monthly bleeds are expected after transitioning to this regimen.

Option 3: My Periods Are Heavy

• HRT Options: This should be initiated after investigations to determine the cause of bleeding. Common causes for heavy periods in this age group include: fibroids, polyps, adenomyosis and perimenopausal hormonal imbalances (ie estrogen dominance of perimenopause). There are a number of options that can sddress both heavy bleeding and menopausal symptoms.
  • Mirena IUD: Provides localized progestogen to reduce heavy bleeding, combined with estrogen (patch, pill, or gel).
  • Cyclical Combined HRT: If periods are still regular but symptoms are present, this may be an option.
  • Progestogen only HRT: some women use cyclical progesterone or a progestogen to bring the estrogen/progesterone ratio back into balance.
  • Hysterectomy: this option typically occurs when hormonal support is insufficient to reduce heavy bleeding.

Option 4: I Have Had a Hysterectomy

• HRT Option: Estrogen-only HRT, as no progestogen is needed and no contraception is needed. 
• What to Expect:
  • Estrogen improves symptoms like hot flashes and supports bone health.
  • Fewer side effects compared to combined HRT (no vaginal bleeding).
  • Some women may want to add natural progesterone if they have symptoms not fully managed with estrogen alone. 

Option 5: I Have Had My Ovaries Removed or Have Premature Ovarian Failure (POF)

• HRT Option: Estrogen replacement is critical to protect against early-onset risks of estrogen deficiency (e.g., osteoporosis, cardiovascular disease).
• What to Expect:
  • Higher initial estrogen doses may be required depending on symptoms.
  • Progestogen may be needed if you still have a uterus.

Option 6: I Have Vaginal Dryness

• HRT Option: Vaginal estrogen is a localized treatment that specifically targets symptoms of vaginal dryness, without the need for systemic HRT. It can be used as a stand alone treatment or alongside other HRT if vaginal symptoms persist. Where topical estrogen is insufficient, DHEA pessaries may be helpful. 

• What to Expect:

  • Significant improvement in vaginal dryness, elasticity, and natural lubrication.

  • Relief from discomfort during daily activities and pain during sex.

  • Reduced risk of urinary tract infections (UTIs) and bladder irritation.

  • Minimal systemic absorption, making it a safe option for most women, even those who cannot take systemic HRT.

• Forms of vaginal estrogen Available (Depends on your country's access)

  • Creams: Applied directly to the vagina using an applicator.
  • Pessaries (tablets): Inserted into the vagina for easy use.
  • Rings: A flexible device placed in the vagina that releases estrogen continuously over several months.

Option 7: I Have Low Libido

• Testosterone levels halve between ages 20 and 40 and continue to drop through to menopause contributing to low libido, low energy, loss of muscle mass and for some, lower mood. 
• HRT Option: Testosterone is a well-validated treatment for low libido which is due to low testosterone levels (libido is complex and a variety of biological, social and psychological factors contribute to it). 
• What to Expect:
  • An improvement in libido over 3-6 months of use. 
  • Monitoring of testosterone is important to ensure your levels are in the female physiological range. 
  • Learn More: Your Guide to using Testosterone in Menopause

General Tips for Starting HRT

• Monitor Your Symptoms: Keep a symptom diary to track your progress and adjust doses if needed.
• Personalize Your Plan: HRT options come in many forms (patches, gels, pills, sprays, or IUDs). Choose what fits your lifestyle.
• Regular Check-Ins: Schedule follow-ups to ensure the treatment is effective and to reassess your needs.

HRT side effects

Side effects can occur from HRT. These are often less when a low dose is started and the dose is titrated up to reduce symptoms. Side effects should be discussed with your prescribing health professional.

• Skin: Skin pigmentation, irritation, or a rash at site of patch or gel application
• Breast: Breast tenderness, pain, swelling, or new lumps 
• Head: Headaches
• Gastrointestinal: Nausea, vomiting, constipation, gas, heartburn, or stomach pain
• Weight: Weight gain or loss
• Bleeding: Painful periods, vaginal bleeding after menopause, or bleeding between scheduled periods
• Other: Hair loss, unwanted hair growth, or changes in libido

Frequently Asked Questions about Menopause Hormone Therapy

Is hormone replacement therapy necessary?

No. Some women get through perimenopause without using any HRT. Some women use herbs or supplements to support their hormones and mood during perimenopause such as ashwagandha or magnesium and this is sufficient.

Other women find that self-care through nutrient-dense food, exercise, connection lowering stress and sleeping well helps them flourish during perimenopause.

The symptoms and experience of perimenopause is unique to each woman and if hormone therapy sounds like it would be helpful for you, speak with your doctor.

What should I expect when I go to see my doctor about menopause hormone therapy?

1. Your doctor will take a history and sometimes a clinical examination to determine safety and risks of MHT for you.

2. Check your mammograms and cervical screening is up to date.

3. Discuss with you the benefits and risks and various options.

4. See your doctor if you have any unexplained vaginal bleeding.

Should I still take HRT after menopause?

Menopausal symptoms can often continue for a number of years after your periods have ceased. Many women continue to use HRT until their symptoms have settled. Women who stop using HRT may continue to have symptoms of low hormones lifelong.

An annual review with your doctor will provide you with the opportunity to discuss how your therapy is going and when (or if) to consider reducing or stopping HRT.

As there are benefits for heart health, longevity, bone health, and wellbeing benefits, many women continue to use HRT indefinately or until they develop a contraindication (a medical reason to stop HRT).

A recent study of over 10 million women shows there are significant health benefits to women who continue to use estrogen HRT after age 65 including:

• 16% reduced risk of breast cancer,

• 13% reduced risk of lung cancer,

• 12% reduced risk of colorectal cancer,

• 5% reduced risk of congestive heart failure,

• 3% reduced risk of venous thromboembolism,

• 4% reduced risk of atrial fibrillation,

• 11% reduced risk of a heart attack and

• 2% reduced risk of dementia.

Reducing these health conditions is essential as each of these can significantly impair quality and duration of life.

Can I take natural hormone replacement therapy after hysterectomy

Yes, after a hysterectomy you can take estrogen only therapy. If you are wanting a natural option then body identical estradiol is a good option for you.

Is progesterone and progestin the same thing?

Progesterone and progestins are not the same thing.

Micronized progesterone is a body identical hormone. It is the same progesterone molecule produced by your own ovaries and therefore is metabolized by same metabolic pathways as it is degraded by the body. It is also known as natural progesterone.

Importantly progesterone is metabolized to allopregnenalone a neurosteroid by the liver, this has a calming effect on the brain.

Progestins are not body identical hormones. They are not metabolized in the same metabolic pathways as progesterone is by the body.

Micronized progesterone is a safer option in terms of breast cancer risks than synthetic progestins (Lewis 2019). A progestin that appears to have a similar safety profile to natural progesterone is dydrogesterone.

Learn more about hormones and breast cancer risk - it's complex

How Long After Starting HRT Do You Feel A Difference?

Time to improvement varies between women and is influneced by both the type of HRT and the starting dose of HRT and your stage of menopause. Some women notice improvement in some symptoms such as sleep and hot flashes within days of starting HRT if they start on a sufficient enough dose.

Other symptoms like mood changes and brain fog can take a month or two before changes are felt, but improvements may continue over 3-6 months.

If you do not notice any improvement or only marginal improvements you may need an increase in your HRT dose, so talk to your health provider.

Discussing Your Options:

Menopause hormone therapy can be life-changing for women with (peri)menopause symptoms that do not improve with lifestyle changes, herbs or supplement support. Talk to your doctor to collaborate on which option will be best for you and this will be based on your menopausal stage, symptom severity, and lifestyle preferences. They may transition you from a cyclical to a continuous regimen as your menopause progresses.

Remember, wellbeing needs a holistic approach; menopause hormone therapy is just one piece of the puzzle.

**Menopause Hormone Therapy should be prescribed by trained medical professionals. It is licenced to treat the symptoms of natural or surgically induced menopause. Estradiol is also licenced for the prevention of postmenopausal osteoporosis. Ask your doctor about the benefits and risks of using MHT and whether it is right for you. If you have any side effects or concerns, speak to your health professional. MHT has benefits and risks. Always follow your doctor’s instructions. For more information refer to the Consumer Medicine Information for estradiol/estriol/progesterone at www.medsafe.govt.nz.