HRT in New Zealand: What women need to know now

You’re thinking about HRT, now more commonly called menopausal hormone therapy or MHT, but should you go on it at all? If you do, should it be a patch, gel or tablet? How do you know what dose is right, whether you need blood tests, and what the breast cancer risk really looks like? Menopause specialist Dr Anna Fenton explains what HRT can actually help with, where the evidence sits and what women should be asking before and after they start treatment.

When I first interviewed Dr Anna Fenton about menopause several years ago, getting women access to reliable information about hormone replacement therapy (HRT) was an uphill battle.

The fallout from the Women's Health Initiative study, published in the early 2000s, had fundamentally changed the way HRT was viewed. Women were frightened of it, and many doctors were reluctant to prescribe it.

Now the conversation could hardly be more different.

Menopause is everywhere. HRT is discussed on podcasts, Facebook groups and Instagram feeds. Women swap notes about patches and progesterone, compare doses and arrive at GP appointments armed with information they have found online.

Fenton says when it comes to our understanding of HRT, we have in many ways "come full circle".

"We're back to where we were pre-2002 before all the concern about hormone therapy erupted."

The challenge now is not convincing women that HRT exists. It is helping them work out what the evidence actually says and what treatment makes sense for them.

What can HRT actually do?

For women experiencing moderate to severe menopausal symptoms, Fenton says hormone therapy can provide significant quality-of-life benefits.

It can also protect bone health  and reduce and heart disease risk.

Timing matters too.

"If it started closer to menopause, so within the first 10 years of your period stopping, it seems likely to significantly reduce the risk of heart disease," she says.

If HRT is started later, more than 10 years after periods stop, Fenton says those heart benefits are lost, although women may still gain symptom relief and protection for their bones.

"There is that, what they call a window of opportunity, where the benefits are greater if it started closer to menopause."

That does not mean every woman should automatically start HRT at menopause. Age, symptoms, health history and individual risk factors all matter.

And according to Fenton, that becomes particularly important when deciding how HRT should be delivered.

Does everyone really need a patch?

If you have spent any time in a menopause Facebook group, there is a good chance you have absorbed one fairly strong message: oestrogen through the skin is safer, so patches or gels are the gold standard.

Fenton says it is not that simple.

"This is one of my kind of pet issues at the moment."

There are women for whom transdermal oestrogen, delivered through the skin by patch or gel, is preferable.

That includes women starting hormone therapy after 60 and those with particular risk factors for blood clots. Certain other health conditions can also make transdermal treatment the better option.

But Fenton says women starting HRT closer to menopause, who are under 60 and do not have those additional clotting risk factors, may also be suitable candidates for oral oestrogen.

"Then tablets are absolutely fine."

Oral oestrogen was the mainstay of hormone therapy for decades, she says.

Over the past few years, however, the message that everybody should use a patch has gained traction. Fenton believes this has contributed to increased demand for patches and the shortages experienced internationally.

For many women without those additional risk factors, the choice may come down to what works best and what they find easiest to use.

One size doesn't fit all

There is another reason Fenton is wary of treating one form of HRT as universally superior.

Some women simply do not absorb oestrogen particularly well through their skin.

She sees women whose patch or gel dose has been increased repeatedly, yet they are still having hot flushes or struggling to sleep. Switching to a tablet can sometimes solve the problem.

"It's a horses for courses thing. What's easiest, what's appropriate for the patient?"

For women who need higher doses of oestrogen to control symptoms, multiple patches or large quantities of gel can also become cumbersome.

"The therapy really does have to be individualised rather than everyone being prescribed the same thing because it may not be the best option for them."

That is worth remembering in a menopause conversation that can sometimes make treatment sound surprisingly formulaic.

Start with this patch. Add this progesterone. Increase to this dose.

Real life is usually messier.

Which symptoms should HRT actually help?

The list of symptoms attributed to menopause online has become impressively long.

Brain fog, anxiety, poor sleep, irritability, weight gain, joint pain, headaches, dizziness, low mood and fatigue can all appear in menopause conversations.

But Fenton says we need to distinguish between symptoms that research clearly connects with menopause and symptoms that may occur at midlife for other reasons.

Changes in temperature regulation, including hot flushes and sweating, sleep disturbance, joint and muscle aches, and mood changes such as irritability, anxiety and low mood all have a clearer relationship with menopause.

Those symptoms should generally respond well to an appropriate dose of hormone therapy.

Brain fog is less straightforward.

Although cognitive complaints show up consistently in menopause research, they do not reliably improve when women are given HRT.

"There's something else going on that drives that," Fenton says.

Researchers still do not fully understand whether poor sleep, changes in other hormones or other factors are contributing.

Weight and changes in body shape are another area where oestrogen is not necessarily the answer.

"They don't automatically respond to oestrogen."

That distinction matters. If a symptom continues despite increasing doses of HRT, the answer may not always be more HRT. It may be worth asking whether something else is causing it.

How do you know if your dose is right?

Anyone who has been prescribed a patch labelled 25, 50 or 75 may have wondered exactly how anybody knows which number they are supposed to land on.

There isn't one perfect dose.

Fenton says symptoms themselves are often the most useful guide. Clear menopausal symptoms such as hot flushes and sweating should largely settle when the dose is right.

"If you start to get breast tenderness, you could be on  too much," she says.

At the same time, symptoms need time to respond.

"It can take six to eight weeks to see the full effect of any dose adjustment."

So changing the dose after a week or two because nothing dramatic has happened may simply be too soon.

Do you need regular blood tests?

Another idea circulating online is that women should have their hormone levels checked regularly to make sure they have reached the "right" oestrogen level.

Fenton says that is generally unnecessary.

Blood tests can be useful when something doesn't add up. If a woman is using a substantial dose of oestrogen and symptoms that should respond are not improving, testing may help establish whether she is absorbing or metabolising the medication differently.

But blood oestrogen levels are not a perfect measure of how well treatment is working.

"Everyone has a different threshold that they need to get to, so there's no sort of standard dose."

She is particularly wary of claims that every woman needs to achieve a certain blood oestrogen level to protect her bones.

"That's not true."

The part of menopause we don't talk about enough

Hot flushes may be the symptom most readily associated with menopause, but some of the changes that have the biggest impact on women's lives happen elsewhere.

Vaginal and urinary symptoms can emerge several years into menopause, even in women already taking systemic HRT.

Fenton says women may experience vaginal dryness, painful sex, recurrent bladder infections or drying, cracking and splitting of vulval tissue.

Sometimes the oestrogen delivered by a tablet, patch or gel simply isn't enough to treat those local symptoms.

That is where vaginal oestrogen can be useful.

It is available in New Zealand in locally applied forms, and Fenton says it can be extremely effective.

These symptoms are also different from hot flushes in one important respect. They don't necessarily settle as women move further beyond menopause.

"They become more of an issue progressively with time."

Fenton says vaginal oestrogen is a very safe and effective treatment for women experiencing these symptoms, yet historical warnings associated with systemic hormone therapy have contributed to unnecessary fear around local oestrogen products too.

Painful sex or recurrent bladder infections are not necessarily things women simply have to accept as part of getting older.

And what about breast cancer?

For many women, this is still the question sitting underneath every conversation about HRT.

Fenton says our understanding of the relationship between hormone therapy and breast cancer has become considerably more nuanced since the original Women's Health Initiative results.

"The breast cancer risk is related to the progesterone component of the hormone therapy. It's not an oestrogen thing," she says.

The WHI included an oestrogen-only group involving women who had undergone hysterectomy, as well as a group taking both oestrogen and an older synthetic progestogen.

Fenton says breast cancer diagnoses were lower in the oestrogen-only group and deaths from breast cancer were also reduced.

When the older synthetic progestogen was added, that benefit disappeared.

Among women starting combined hormone therapy for the first time in the study, Fenton says there was no increase in breast cancer risk during the first seven to eight years of follow-up.

"So if there is an increase, and we assume there is, it happens sometime after that seven or eight years of use."

She says the additional risk seen with the older synthetic progestogens was small in absolute terms.

The type used alongside oestrogen may matter too.

Micronised progesterone, a body-identical form of progesterone, has become widely preferred. Fenton says long-term observational research suggests it may carry a much lower breast cancer risk than the older synthetic progestogens.

"That's why that's become the preferred form of progesterone rather than the older-fashioned, more synthetic ones."

This is an area where individual medical history matters, and where a frightening headline or percentage on its own rarely tells the whole story.

It is also a good example of why treatment decisions are better made with a clinician who understands your circumstances than through somebody else's experience online.

What if your GP isn't confident about menopause?

Access to menopause care has improved, but not every GP will necessarily feel confident in this area.

If you feel your concerns are being dismissed or your doctor is reluctant to discuss treatment options, Fenton suggests asking whether somebody else within the practice has a particular interest in menopause or women's health.

There are also more GPs offering dedicated women's health services, including via telehealth.

"They are more accessible even if a patient is based very rurally. They can still access online someone with some expertise."

That is a significant shift from the menopause landscape of even a few years ago.

The question isn't simply: should I take HRT?

For years, the menopause conversation was dominated by whether HRT was "safe" or "dangerous".

That increasingly looks like the wrong question.

A more useful conversation considers what symptoms you are trying to treat, your age and health history, how long it has been since your periods stopped, which form of oestrogen suits you, whether you need progesterone, and whether the symptoms troubling you are actually likely to respond to hormones.

HRT can make an enormous difference to quality of life for some women.

But there isn't one prescription, one dose or one way to do it.

In a menopause conversation increasingly filled with definitive statements about what every woman "should" be taking, Fenton's advice is considerably less dramatic.

There is no universal HRT prescription. The right option depends on the woman, her symptoms and her circumstances.

About Dr Anna Fenton

Dr Anna Fenton is a Christchurch-based gynaecological endocrinologist and menopause specialist.

A note about medical information

This article is for general information and education only. It is not personalised medical advice and is not a substitute for advice from your own health professional. Your medical history, symptoms and individual risk factors can affect whether hormone therapy is appropriate for you and which treatment may be most suitable.