Menopausal Hormone Therapy (MHT/HRT) in Turkey

What Is Menopausal Hormone Therapy (MHT)?

Menopausal hormone therapy is a personalized menopause treatment approach used to manage conditions caused by declining estrogen levels during menopause, such as hot flashes, night sweats, sleep disturbances, vaginal dryness, pain during intercourse, urinary sensitivity, reduced quality of life, and bone loss. Menopausal hormone therapy is commonly abbreviated as MHT.

It is more widely known as “hormone therapy” or “HRT” (hormone replacement therapy). When patients are selected appropriately, menopausal hormone therapy can be an important option for controlling menopause symptoms.

The Relationship Between Hormone Replacement Therapy (HRT) and Menopausal Hormone Therapy

Menopausal hormone therapy is not a single drug or a single prescription. It is planned in different ways depending on whether the patient has a uterus, her age, how long it has been since menopause, the type of symptoms, her risk of breast and uterine cancer, her risk of blood clots, her risk of cardiovascular disease, and additional conditions such as migraine or liver disease.

For some patients, vaginal estrogen alone may be sufficient, while others require systemic estrogen therapy that affects the whole body. In patients with a uterus, progesterone or a progestogen is usually added to estrogen to protect the endometrium, the inner lining of the uterus. For this reason, menopausal hormone therapy is not a standard procedure; it is an individual treatment planned specifically for each patient.

What Is Bioidentical Hormone Therapy?

To understand menopausal hormone therapy correctly, two extremes must be avoided. At one extreme is the belief that “hormones are very dangerous and should never be used.” At the other is an unscientific and overly ambitious view that “every woman should use hormones; hormones stop aging.”

The current approach lies between these two extremes and is based on a personalized benefit–risk assessment. The NAMS (North American Menopause Society) 2022 position statement emphasizes that menopausal hormone therapy (MHT) is the most effective treatment, particularly for vasomotor symptoms and genitourinary syndrome of menopause, and that its risks vary according to the type of treatment, dose, duration, route of administration, and timing of initiation. Within this framework, bioidentical hormone therapy, conventional HRT, and other menopausal hormone therapy options are evaluated using the same personalized approach.

The Basic Approach to Menopausal Hormone Therapy

In menopausal hormone therapy, the key question is not “Are hormones good or bad?” The truly important questions are:

• How significant are the patient’s symptoms?
• How old is she, and how many years have passed since menopause?
• Does she have a uterus?
• Is there a risk of breast cancer, uterine cancer, cardiovascular disease, or blood clots?
• Is vaginal or systemic treatment needed?
• Which dose and route of administration are safer?

The answers to these questions allow treatment to be personalized. For patients seeking menopause treatment or menopausal hormone therapy in Ankara, Turkey, the goal is not to start a one-size-fits-all treatment, but to determine the right treatment approach for the right patient through a detailed evaluation.

Why Are Hormones Important During Menopause?

Menopause is the stage in which menstrual periods stop permanently as a result of a marked decrease in estrogen and progesterone production due to declining ovarian function. Menopause is diagnosed after 12 months without a menstrual period. However, menopause is not a one-day event that happens all at once. During the transition period called perimenopause, irregular periods, hot flashes, sleep problems, mood changes, vaginal dryness, and metabolic changes may begin.

Estrogen is not just a hormone that regulates the menstrual cycle. It affects the brain’s temperature-regulation center, vaginal and urethral tissues, bone metabolism, the skin, sleep patterns, and certain vascular functions. For this reason, declining estrogen during menopause does not simply mean that periods stop. While some women experience mild symptoms, others may develop complaints that significantly affect their daily life, work performance, sleep quality, sex life, and emotional well-being.

Hot flashes and night sweats are among the most typical symptoms of menopause. They are referred to as vasomotor symptoms. These symptoms can disrupt sleep, cause a sensation of palpitations, affect social life, and cause brain fog, and in some patients they may last for years. Vaginal dryness, burning, pain during intercourse, frequent urination, and recurrent urinary tract infections are evaluated under the heading of genitourinary syndrome of menopause. These complaints may persist or worsen over the years, even after systemic hot flashes have resolved.

Bioidentical hormone therapy is not used in the same way for all of these symptoms. In a patient with prominent hot flashes and night sweats, systemic hormone therapy may be considered. In a patient with only vaginal dryness and painful intercourse, low-dose vaginal estrogen or other local treatments are often sufficient. This distinction is very important for treatment safety.

Who Is Menopausal Hormone Therapy Suitable For?

Menopausal hormone therapy is considered particularly for women with hot flashes, night sweats, sleep disturbances, and reduced quality of life who are generally under the age of 60 or within the first 10 years after menopause, and whose personal risk assessment is favorable. This period is known as the “window of opportunity.” The “timing hypothesis” shows that the benefit/risk balance of menopausal hormone therapy is closely related to when treatment is started.

The 2025 guideline update also emphasizes that menopausal hormone therapy is the most effective treatment for vasomotor symptoms in healthy women under 60 or within 10 years of menopause.

Menopausal hormone therapy (MHT) is important not only for hot flashes but also for women with early menopause or primary ovarian insufficiency (premature ovarian failure). Loss of ovarian function before the age of 40 is evaluated differently from natural menopause. Because estrogen deficiency begins earlier in these patients, hormone therapy is often recommended until the age of natural menopause for bone health, cardiovascular risk, urogenital health, and quality of life. In fact, in these women, the treatment is properly termed “hormone replacement therapy (HRT).” ACOG (American College of Obstetricians and Gynecologists) states that hormone therapy should be used in primary ovarian insufficiency to reduce the risk of osteoporosis, cardiovascular disease, and urogenital atrophy and to improve quality of life.

In patients who have a uterus and will use systemic estrogen, the addition of progesterone is usually necessary. This is because estrogen can stimulate the inner lining of the uterus and increase the risk of endometrial hyperplasia and endometrial cancer. In patients who have had their uterus removed, estrogen alone can often be used. However, the approach may differ in special situations such as a history of endometriosis, subtotal hysterectomy, or the possibility of remaining endometrial tissue.

Eligibility for menopausal hormone therapy is not determined by age alone. If the patient has a history of breast cancer, unexplained vaginal bleeding, active or previous blood clots, stroke, heart attack, active liver disease, a history of endometrial cancer, high-risk thrombophilia, or uncontrolled serious illness, menopausal hormone therapy (MHT) may not be suitable or may require much more careful evaluation. For this reason, a detailed history and risk assessment must be carried out before writing a prescription.

Who Is Menopausal Hormone Therapy (MHT) Not Suitable For?

Menopausal hormone therapy (MHT) is not recommended for some patients. A history of breast cancer, especially hormone receptor-positive breast cancer, is an important contraindication to systemic MHT. If there is unexplained vaginal bleeding, its cause should be investigated first. Estrogen should not be started before endometrial hyperplasia or suspected uterine cancer has been ruled out.

Active vascular occlusion, deep vein thrombosis, pulmonary embolism, or a history of stroke or heart attack are very important in the decision regarding MHT. Oral estrogen preparations in particular increase the risk of blood clots. Although transdermal estrogen, applied through the skin, has been associated with a lower risk of thromboembolism in some patients, the decision must be made individually and carefully in patients with a history of blood clots. MHT is often not suitable in high-risk thrombophilia, active liver disease, or uncontrolled serious systemic diseases either.

It cannot be said that MHT is strictly prohibited for every woman with a family history of breast cancer. Here, the degree of family history, genetic risk, personal breast findings, mammography/breast ultrasound results, the patient’s age, the severity of symptoms, and alternative treatment options are evaluated together. However, in patients with a personal history of breast cancer, MHT is not given except in special circumstances. These patients are advised to use non-hormonal treatments and lifestyle approaches. When necessary, the decision on hormone therapy should be made together with medical oncology.

Before starting hormone replacement therapy, the answer to the question “Can I be given hormones?” is not based solely on a blood test. A detailed medical history, bleeding history, breast evaluation, blood pressure, weight, metabolic risks, medications, family history, and the patient’s goals should all be evaluated together. If treatment is not suitable, this does not mean the patient will be left alone with her symptoms. Non-hormonal medications, local vaginal treatments, lifestyle changes, and behavioral approaches can be used.

The Difference Between Systemic Menopausal Hormone Therapy and Local Vaginal Treatment

One of the most important distinctions in menopausal hormone therapy is between systemic and local treatment. Systemic MHT is treatment that targets hot flashes, night sweats, sleep disturbances, and general menopause symptoms. It can be administered orally as tablets or through the skin as patches, gels, or sprays. This treatment enters the bloodstream and acts throughout the body.

Local vaginal estrogen therapy, on the other hand, mainly targets symptoms of estrogen deficiency in the vagina and lower urinary tract. It can be used for vaginal dryness, burning, pain during intercourse, vaginal sensitivity, recurrent urinary tract infections, and some urinary irritation. The systemic absorption of low-dose vaginal estrogen is generally very low, and it does not have the same risk profile as systemic MHT. The NAMS (North American Menopause Society) 2022 statement indicates that low-dose vaginal estrogen or other local treatments may be considered for patients with genitourinary syndrome of menopause who do not have an indication for systemic MHT.

This distinction is very important for patients. It may not be necessary to give systemic hormone therapy to a woman who has only vaginal dryness and painful intercourse. Conversely, a vaginal cream alone will not be sufficient for a patient with severe hot flashes and night sweats. Treatment should be chosen according to the source of the complaint.

In 2025–2026, changes by the FDA (U.S. Food and Drug Administration) to remove broad “black box” warnings from menopausal hormone therapy labels reinforced current discussions emphasizing that systemic MHT should be evaluated on a more individualized basis according to age and time since menopause. However, the FDA has stated that the endometrial cancer warning related to systemic estrogen-only use in women with a uterus will be retained, and that the label will recommend initiating systemic MHT generally within 10 years of menopause or before the age of 60.

Types of Menopausal Hormone Therapy: Estrogen, Progesterone, and Combined Treatments

The main component of menopausal hormone therapy (MHT) is estrogen. Most menopause symptoms are related to declining estrogen. However, if estrogen is given alone to women who have a uterus, the uterine lining may be continuously stimulated, increasing the risk of endometrial hyperplasia and uterine cancer. For this reason, progesterone or a progestogen is usually added to estrogen therapy in patients with a uterus.

The role of progesterone is to balance the stimulating effect of estrogen on the uterine lining. This protection is very important for treatment safety. In women who have had their uterus removed, progesterone usually does not need to be added because there is no endometrium. However, the approach is individualized in cases such as a history of endometriosis, subtotal hysterectomy (in which the cervix is left in place),or other special situations.

Combined treatments can be given continuously or cyclically:

• In continuous combined therapy, estrogen and progesterone are taken every day. It may be preferred in patients for whom a bleed-free regimen is the goal.
• In cyclical therapy, estrogen is given continuously, while progesterone is added on certain days of the month. This approach may cause regular withdrawal bleeding in some patients. In the perimenopausal period or the early menopausal transition, a cyclical regimen may sometimes be more appropriate.

The choice of progesterone is also important. Micronized progesterone, dydrogesterone, and various synthetic progestins differ in their metabolic, breast, vascular, and side-effect profiles. Factors such as sleep disturbances, breast tenderness, mood changes, bleeding pattern, clotting risk, and tolerance may influence the choice of treatment. For this reason, menopausal hormone therapy is not just a matter of “let’s give estrogen”; it involves setting up the entire regimen correctly.

Oral, Transdermal, and Vaginal Routes of Administration

Menopausal hormone therapy (MHT) can be administered orally as tablets, through the skin as patches, gels, or sprays, or as vaginal preparations. When planning menopausal hormone therapy, the route of administration is at least as important as the medication itself.

Oral estrogen undergoes first-pass metabolism in the liver. For this reason, the transdermal route may be more advantageous in terms of clotting risk and certain metabolic effects. Transdermal estrogen, which is applied to the skin, passes into the bloodstream through the skin. Therefore, transdermal menopause treatment may stand out in some patients, particularly in terms of safety and tolerability.

Transdermal treatments may be in the form of patches, gels, or sprays. Dose adjustment can be more flexible, and some patients experience fewer gastrointestinal side effects. However, practical issues such as skin irritation, sensitivity at the application site, or usage habits should be taken into account.

Oral treatment, on the other hand, may be easier for some patients to use. In other words, the route of administration is chosen not only according to medical risks but also according to the patient’s lifestyle and adherence. For this reason, menopause treatment should not follow a standard scheme, but should be planned individually by evaluating the patient’s symptoms, risks, and expectations together.

Vaginal treatments differ from systemic MHT. Low-dose vaginal estrogen can be applied as a cream, tablet, ring, or similar form. The aim is to moisturize the vaginal tissue, increase its elasticity, reduce the feeling of burning and dryness, and relieve pain during intercourse. In some patients, it may also be beneficial for recurrent urinary tract infections and urinary sensitivity. For this reason, treating vaginal dryness during menopause does not always require systemic hormone therapy; local vaginal treatments may be sufficient for some patients.

When choosing the route of administration, the patient’s expectations and risk profile should be evaluated together. If hot flashes predominate, systemic treatment is needed; if vaginal dryness predominates, local treatment is often sufficient. In a patient with a high risk of blood clots, the transdermal route is considered instead of the oral route. However, in very high-risk patients, it may be necessary to avoid systemic MHT altogether.

When evaluating bioidentical hormone therapy, menopausal hormone therapy, or other menopause treatment options, the basic approach is the same: choosing the right dose and the right route of administration for the right patient. For patients seeking menopause treatment in Ankara, the decision should also be based on a personal risk analysis and a detailed physician evaluation.

Benefits of Menopausal Hormone Therapy (MHT)

The strongest benefit of menopausal hormone therapy is the reduction of hot flashes and night sweats. While these symptoms are mild in some women, in others they may cause sleep disturbances, fatigue, reduced concentration, decreased work performance, and limitations in social life. Systemic MHT is considered the most effective menopause treatment option for these symptoms. The NICE (National Institute for Health and Care Excellence, UK) 2024 update also adopted an approach that highlights the role of hormone replacement therapy in hot flashes, night sweats, sleep, and quality of life in women with menopause symptoms.

Menopausal hormone therapy may also improve sleep quality. This effect may be particularly noticeable in patients who wake up frequently due to night sweats. However, sleep disturbances are not always caused solely by menopause. For this reason, other causes should also be reviewed. Sleep apnea, depression, anxiety, thyroid disease, pain, medications, and lifestyle factors should also be evaluated.

Menopausal hormone therapy can reduce bone loss and lower the risk of fractures. NAMS (North American Menopause Society) 2022 states that hormone therapy is effective in preventing bone loss and fractures. However, MHT is not a treatment to be started for everyone solely for bone health. In the treatment of osteoporosis, age, fracture risk, vitamin D, calcium intake, exercise, and other osteoporosis medications should also be evaluated. For this reason, menopausal hormone therapy should also be planned with a personal risk assessment in terms of bone health.

Menopausal hormone therapy may also be beneficial for vaginal and urogenital symptoms. However, if these are the only symptoms, vaginal treatment alone is often more appropriate. In some women using systemic MHT, vaginal dryness may not resolve completely. In this case, additional local treatment may be required. This shows that menopause treatment is not something that ends with a single examination and a single prescription; it is a process that requires follow-up, assessment of response, and adjustment when necessary.

Risks of Menopausal Hormone Therapy

The risks of menopausal hormone therapy vary according to the type of treatment, age, timing of initiation, route of administration, dose, duration, whether the woman has a uterus, and personal risk factors. For this reason, it is not correct to describe the risk of MHT in a single sentence such as “hormones cause cancer” or “hormones are completely safe.” Risks should be individualized. The same balance of benefits and risks should be considered when evaluating bioidentical hormone therapy, hormone replacement therapy, or conventional menopausal hormone therapy options.

The risk of breast cancer may increase in relation to treatment duration, particularly with combined estrogen and progesterone therapy. However, this risk is not the same in absolute terms for every patient. The type of progesterone used, the duration of treatment, the patient’s baseline risk, family history, breast density, and lifestyle factors are important. The effect of estrogen-only therapy on breast cancer is different and is distinguished from combined therapy in the WHI study data.

The risk of blood clots is also important. Oral estrogen can increase the risk of venous thromboembolism. Transdermal estrogen is thought to be more advantageous in terms of clotting risk. The decision on systemic treatment should be made carefully in high-risk patients. Obesity, smoking, previous blood clots, thrombophilia, immobilization, and advanced age can increase the risk. For this reason, when planning menopausal hormone therapy, oral and transdermal routes should be evaluated separately according to the patient’s risk profile.

The risk of stroke and cardiovascular disease becomes more significant, especially when treatment is started at an older age or long after menopause. For this reason, MHT should not be started to prevent heart disease. The USPSTF 2022 does not recommend the routine use of MHT for the prevention of chronic diseases. This recommendation does not cover the use of hormone therapy to treat menopause symptoms such as hot flashes, night sweats, or vaginal dryness, and the two should not be confused. It refers to patients without symptoms. Therefore, hormone therapy during menopause is not planned for prevention purposes. It should be planned to relieve significant menopause symptoms in the right patient and with a personalized benefit–risk assessment.

In women with a uterus, estrogen should not be used alone, because it can increase the risk of endometrial hyperplasia and endometrial cancer (cancer of the uterine lining). For this reason, progesterone protection is very important. If unexplained bleeding develops, an evaluation should be carried out rather than continuing treatment. For patients seeking menopause treatment or menopausal hormone therapy in Ankara, these risks should also be addressed by evaluating the patient’s age, symptoms, uterine status, breast disease risk, and cardiovascular risks together.

The WHI Study and How Views on Menopausal Hormone Therapy Have Changed

At the center of modern discussions about menopausal hormone therapy are the WHI (Women’s Health Initiative) studies. The WHI results published in 2002 raised concerns about certain risks, particularly of combined hormone therapy, and led to a marked decline in the use of hormone replacement therapy (HRT) worldwide. After that period, many patients and physicians became more cautious about hormone therapy.

However, as the WHI data were analyzed in more detail over time, it became clear that many of the study participants started treatment years after menopause and at an older age. This may not represent the same benefit–risk balance as symptomatic women in early menopause. For this reason, the current approach accepts that MHT should be evaluated differently according to age and time since menopause. In addition, the results of subgroup analyses of the study were later reinterpreted.

This does not mean that the WHI is unimportant. On the contrary, the WHI is very valuable in showing that MHT should not be given to everyone to prevent chronic diseases. However, interpreting the WHI results as “no woman should use hormones” is also not consistent with the current scientific approach. MHT can be used on a personalized basis in symptomatic women with a suitable risk profile in early menopause.

The FDA’s 2025–2026 label updates have also drawn attention as a regulation that supports an information approach based on age, indication, and risk profile instead of broad, one-size-fits-all fear-based language. However, this change does not mean that MHT is risk-free or that it is a general anti-aging treatment.

Is Menopausal Hormone Therapy Used for Heart, Bone, and Brain Health?

Menopausal hormone therapy has positive effects on bone. It can reduce bone loss and lower the risk of fractures. However, it is not correct to start MHT for everyone solely to prevent osteoporosis. Hormone therapy should not be started only to stop bone loss when there is no other reason. In patients at high risk of osteoporosis, bone mineral density, fracture risk, family history, vitamin D levels, calcium intake, exercise, smoking, and other treatment options should be evaluated together. MHT may provide additional benefits for bone health, particularly in women in early menopause who also have menopause symptoms.

In terms of heart health, MHT should not be used for primary or secondary prevention. In other words, MHT is not a treatment to be started “so that I don’t have a heart attack.” ACOG’s (American College of Obstetricians and Gynecologists) Committee Opinion on hormone therapy and heart disease states that hormone therapy during menopause should not be used to prevent coronary heart disease.

MHT should also be interpreted carefully in terms of brain health and dementia. Using hormone therapy started long after menopause to reduce the risk of dementia is not recommended. During the menopausal transition, various brain-related symptoms such as forgetfulness and brain fog may be observed. In symptomatic women in early menopause, the effect of short- to medium-term MHT on cognitive complaints may vary from person to person; however, MHT is not a treatment for preventing dementia.

Presenting hormone therapy during menopause as an “anti-aging,” “rejuvenating,” or “all-disease-preventing” treatment is not scientific. Statements such as “We stop aging with bioidentical hormone therapy,” “Stay young with hormone replacement therapy,” or “If you take hormones, you won’t age” are completely false propaganda and misleading advertising.

It should be used with the right indications to manage the signs and symptoms encountered during the menopausal transition or menopause.

How Is Breast Cancer Risk Assessed?

The relationship between MHT and breast cancer is one of the issues patients worry about most. This concern is understandable, but the risk needs to be explained in a balanced way. A duration-dependent increase in breast cancer risk may be seen with combined estrogen–progesterone therapy. The breast cancer risk profile of estrogen-only therapy is different. The type of progesterone used and the duration of treatment are also important.

A family history of breast cancer alone does not automatically rule out hormone therapy during menopause, but it does affect the risk assessment. Factors such as breast cancer in first-degree relatives, breast cancer at a young age, bilateral breast cancer, a BRCA mutation, or dense breast tissue should be evaluated separately. High-level risks of this kind are a barrier to hormone use. A personal history of breast cancer, however, is a much stronger limiting factor for systemic MHT.

Before starting hormone therapy during menopause, breast screening appropriate to age and risk status should be performed. The decision on mammography, breast ultrasound, or additional imaging is based on the patient’s age, breast density, and risk profile. Regular breast check-ups should also be continued after treatment has started.

When explaining the risk to patients seeking bioidentical hormone therapy and menopausal hormone therapy in Ankara, the language of absolute risk should be used. Instead of frightening and generalizing statements such as “it causes breast cancer,” it should be explained how the risk may change with which treatment, for how long, and at what baseline risk. The patient’s symptom burden and quality of life are also part of the decision.

Why Is Progesterone Needed in Women With a Uterus?

If systemic estrogen is used alone in a woman with a uterus, the uterine lining may be continuously stimulated. This can increase the risk of endometrial thickening, irregular bleeding, endometrial hyperplasia, and, over time, endometrial cancer. For this reason, progesterone or a progestogen is added to systemic estrogen therapy in women with a uterus.

The purpose of progesterone is not to create a menstrual cycle, but to protect the uterine lining. In hormone replacement therapy, progesterone can be given in continuous combined or cyclical regimens. The choice of regimen depends on the time since menopause, expectations regarding bleeding/periods, the patient’s tolerance, and the clinical situation. If unexpected, heavy, or irregular bleeding occurs during treatment, an evaluation is required.

Progesterone is generally not required in women who have had their uterus removed. However, the approach may differ in special situations such as a history of endometriosis, supracervical (“subtotal”) hysterectomy, or residual endometrial tissue. For this reason, generalizations such as “my uterus was removed, so progesterone is unnecessary” or “progesterone is essential in every hormone therapy” should be avoided.

Endometrial safety is one of the most fundamental safety issues in menopausal hormone therapy. In its label updates, the FDA (U.S. Food and Drug Administration) has also stated that the endometrial cancer warning will be retained for systemic estrogen-only products in women with a uterus.

What Evaluations Are Done Before Starting Menopausal Hormone Therapy?

A detailed history should be taken before starting menopausal hormone therapy. The patient’s age at menopause, date of last menstrual period, severity of hot flashes and night sweats, sleep, vaginal and urinary symptoms, effects on sex life, bleeding history, migraine, history of blood clots, heart disease, stroke, liver disease, breast disease, family history, and current medications should be evaluated.

A physical examination may require checking blood pressure, weight, body mass index, a breast evaluation, and a gynecological examination. Cervical cancer screening (Pap smear and HPV tests) and breast screening should be checked.

If there is unexplained vaginal bleeding, its cause should be investigated first. Bleeding during the menopausal transition or after menopause should never be dismissed simply as “hormone deficiency.”

Blood tests are not the same for every patient. Tests are ordered if thyroid disease, anemia, diabetes, lipid disorders, or other systemic problems are suspected. Metabolic diseases should be regulated and brought under control. In most cases, menopause at a typical age with a typical clinical picture does not need to be confirmed with tests such as FSH. However, hormonal evaluation may be needed in cases of early menopause, primary ovarian insufficiency, or diagnostic uncertainty.

The most important step before treatment is explaining the options to the patient. Systemic MHT, local vaginal treatment, non-hormonal medications, lifestyle changes, cognitive behavioral approaches, and follow-up options should be discussed. The NICE (National Institute for Health and Care Excellence, UK) 2024 update supports explaining the benefit–risk balance of hormone replacement therapy to women according to their personal characteristics and encourages their active participation in the decision-making process.

How Long Is Menopausal Hormone Therapy Used?

The duration of hormone therapy during menopause is determined individually. In the past, the phrase “the lowest dose for the shortest time” was used very often. Although this phrase has not been completely abandoned, a more individualized perspective now prevails. The aim is to use the most appropriate dose and regimen that controls the patient’s symptoms and to reassess the benefit–risk balance at regular intervals.

Some women may stop treatment within a few years as their symptoms subside. In others, hot flashes and night sweats may continue for many years. The decision to stop treatment should be made together with the patient, taking into account her symptoms, age, risks, and preferences. MHT does not need to be stopped automatically every year or necessarily discontinued at a certain age; however, risks should be reassessed at older ages and with long-term use.

In fact, the decision to continue hormone therapy is made together with the patient as the outcome of an ongoing follow-up process with regular risk assessments.

Regular follow-up during treatment is important. Bleeding patterns, breast check-ups, blood pressure, weight, metabolic risks, newly developing diseases, and medications should be reviewed. Treatment is re-evaluated in situations such as unexpected vaginal bleeding, a new breast lump, signs of a blood clot, chest pain, shortness of breath, or signs of stroke.

When stopping MHT, there is no single approach that has been shown to be clearly superior between stopping abruptly and tapering off. In some patients, tapering may make the return of symptoms more tolerable. Others may stop directly. The decision is made according to the patient’s symptoms and preferences.

What Options Are Available Besides Menopausal Hormone Therapy?

Non-hormonal medication options

Non-hormonal treatments can be used in women for whom MHT is not suitable or who do not want to use hormones. For hot flashes, options such as certain antidepressants, gabapentin, clonidine, and neurokinin-3 receptor antagonists may be considered. Fezolinetant is a non-hormonal option developed for moderate to severe vasomotor symptoms and has expanded menopause treatment alternatives in recent years. However, issues such as liver function and drug interactions should be taken into account.

Lifestyle changes

Lifestyle changes alone do not always resolve severe symptoms, but they support treatment. Avoiding hot environments, dressing in layers, reducing alcohol and spicy foods, regular exercise, weight management, sleep hygiene, and stress management may be beneficial for some patients. Regular exercise is also important for bones, muscles, sleep, mood, and cardiometabolic health.

Cognitive behavioral therapy

Cognitive behavioral therapy may be beneficial for some women, particularly in terms of their response to hot flashes, sleep, and coping skills. NICE (National Institute for Health and Care Excellence, UK) 2024 states that cognitive behavioral therapy (CBT) may have a supportive role in women who cannot or do not wish to use hormone replacement therapy (HRT), or for certain symptoms that persist despite HRT. However, CBT should not be presented as a treatment that provides exactly the same biological effect as HRT for severe vasomotor symptoms.

Vaginal dryness and urogenital symptoms

For vaginal dryness and painful intercourse, options such as moisturizers, lubricants, low-dose vaginal estrogen, vaginal DHEA, or ospemifene may be considered depending on the patient. In a patient with only vaginal symptoms, systemic hormone therapy may not be necessary. For this reason, the treatment of vaginal dryness during menopause can be planned individually, separately from systemic menopausal hormone therapy.

Menopausal Hormone Therapy in My Clinical Approach

In my clinical approach, menopausal hormone therapy is not a simple decision of “should we give hormones or not?” For this reason, menopause treatment should be planned not only according to the name of the complaint, but by evaluating the patient’s age, risks, expectations, and quality of life together. First, it is necessary to understand how much the menopause symptoms affect the patient’s life. Are hot flashes disrupting her sleep at night or affecting her work life? Is vaginal dryness making her sex life difficult? Are her mood and energy levels significantly affected? Is there an early risk in terms of bone health? The need for menopause treatment is shaped by these questions.

When considering MHT for a patient, I pay particular attention to her age and the time since menopause. The benefit–risk balance may be more favorable in patients who are generally under 60 or within the first 10 years after menopause, who have significant symptoms, and who have no contraindications. In patients who are older or for whom a long time has passed since menopause, the decision to start systemic MHT should be made much more carefully.

I do not neglect progesterone protection. I always ask about any history of vaginal bleeding. If there is bleeding after menopause, it should be evaluated first. Breast screening, family history, clotting risk, blood pressure, weight, smoking, migraine, liver disease, and medications all affect the treatment decision. Different treatments may be chosen for two women with the same symptoms.

In treatment, I try to choose a personalized, lowest effective dose and an appropriate route of administration whenever possible. Systemic treatment is considered for a patient with hot flashes, local treatment for a patient with only vaginal dryness, the transdermal route for a patient with a higher clotting risk, and appropriate progesterone support for a patient with a uterus.

After treatment begins, I follow up with the patient and readjust the dose and regimen if necessary. This personalized approach should also be maintained when evaluating bioidentical hormone therapy, conventional hormone replacement therapy, or other menopausal hormone therapy options.

I clearly explain to patients that MHT is not a rejuvenating treatment or one that prevents all diseases. Likewise, I tell them that it is not right to be unnecessarily afraid of hormone therapy. Correct patient selection, the right dose, the right route, regular follow-up, and realistic expectations are the foundation of MHT. For patients seeking menopause treatment in Ankara, the goal is not to hand out a routine prescription, but to create a safe treatment plan by evaluating their complaints, risks, and expectations together.

When Should You See a Doctor About Menopausal Hormone Therapy / Hormone Replacement Therapy?

A gynecological evaluation is needed if you have hot flashes, night sweats, sleep disturbances, a sensation of palpitations, vaginal dryness, pain during intercourse, recurrent urinary tract infections, reduced quality of life related to menopause, brain fog, forgetfulness, or suspected early menopause. This evaluation is important not only for prescribing hormones but also for understanding whether the symptoms are truly related to menopause. For this reason, menopausal hormone therapy or non-hormonal menopause treatment options should be planned after an examination and risk assessment.

The cessation of periods, a marked decrease in their frequency, or the onset of menopause symptoms before the age of 40 should be evaluated for primary ovarian insufficiency. This group is different from natural menopause, and hormone therapy is often important not only for symptom control but also for long-term health effects. Fertility awareness and fertility management are also extremely important.

If there is vaginal bleeding after menopause, it must always be evaluated, whether or not the patient is using MHT. Bleeding should not be dismissed as “caused by the hormones.” Evaluation of the uterine lining for polyps, fibroids, hyperplasia, or cancer may be necessary.

Which Symptoms Require Urgent Evaluation?

If a new breast lump, chest pain, shortness of breath, leg swelling and pain, sudden headache, speech disturbance, vision loss, or serious neurological symptoms develop while using MHT, urgent evaluation is required. These findings may be signs of rare but important complications.

Common Misconceptions About Menopausal Hormone Therapy

One of the most common misconceptions about menopausal hormone therapy is the belief that hormone therapy causes cancer in every woman. This is not true. The risks of MHT vary according to the type and duration of treatment, the patient’s age, whether she has a uterus, and her personal and family risks. The risk of breast cancer in particular is related to combined therapy and duration of use. This risk is not the same for every patient.

Another misconception is that MHT is completely harmless and necessary for everyone. This is not true either. Hormone therapy during menopause can be very beneficial for the right patient, but it requires careful evaluation in terms of blood clots, breast, uterine, stroke, and cardiovascular risks. Therefore, it cannot be generalized. Hormones are not automatically given to every woman in menopause.

The idea that “menopausal hormone therapy stops aging” is not scientific. Hormone therapy during menopause provides benefits for hot flashes, night sweats, genitourinary symptoms, and, in selected cases, bone health; however, it is not a treatment that stops aging, completely rejuvenates the skin, or prevents all chronic diseases. There is no scientific evidence for this.

The idea that “a woman with a uterus can use estrogen alone” is dangerous. In women with a uterus, systemic estrogen should generally be balanced with progesterone. Otherwise, the uterine lining may be overstimulated, and the risk of endometrial hyperplasia or cancer may increase.

The idea that “vaginal estrogen carries the same risk as systemic hormone therapy” is also incorrect. The systemic absorption of low-dose vaginal estrogen is much lower, and it has a different safety profile, particularly in patients with only vaginal and urinary symptoms. However, in special situations such as a personal history of breast cancer, an individual evaluation should still be made.

The idea that “herbal hormones are completely safe” is also wrong. Herbal products, phytoestrogens, and supplements also carry risks of side effects, drug interactions, or dose uncertainty! Being “natural” does not automatically mean being safe. Caution should be exercised, especially in patients with a history of breast cancer or liver disease.

Menopausal Hormone Therapy: Summary

When used in the right patient, menopausal hormone therapy is a powerful treatment option that can significantly reduce menopause symptoms, improve quality of life, and support bone health in some patients. Treatment options should be evaluated in detail, particularly in women experiencing hot flashes, night sweats, sleep disturbances, mood swings, vaginal dryness, and reduced quality of life due to menopause. However, hormone replacement therapy during menopause is not a treatment that should be given automatically to everyone. Likewise, rejecting it entirely due to unnecessary fears is not the right approach either. The basic principle of modern menopause management is a personalized benefit–risk assessment for every patient.

When deciding on menopausal hormone therapy, the patient’s age, the time since menopause, the severity of menopause symptoms, whether she has a uterus, her risk status for breast and uterine cancer, her risk of blood clots and cardiovascular disease, the route of administration, dose, and duration of the hormone to be used, and her expectations should all be evaluated together. In women with a uterus, systemic estrogen therapy must be balanced with progesterone; otherwise, undesirable effects on the uterine lining may occur. In patients with only vaginal dryness, pain during intercourse, or urinary complaints, low-dose local vaginal treatments are often sufficient. In contrast, in patients with prominent hot flashes and night sweats, systemic MHT may come into consideration as a more effective option.

When planning treatment during menopause, how much a complaint affects a woman’s life is as important as the type of complaint. In some women, hot flashes are mild, and lifestyle changes, sleep hygiene, weight control, regular exercise, and avoiding triggers may be sufficient. However, in some patients, treatment for hot flashes during menopause becomes a real necessity. Night sweats interrupt sleep, daytime fatigue increases, concentration decreases, and overall quality of life deteriorates significantly. In this case, MHT, non-hormonal treatments, and local treatment options should be evaluated together according to the patient’s risk profile.

For patients seeking menopause treatment in Ankara, the evaluation is not limited to the question “Should hormone therapy be started?” In a woman going through menopause, hot flashes, night sweats, vaginal dryness, pain during intercourse, urinary complaints, bone health, weight changes, metabolic risks, and breast and uterine health should all be addressed together. For this reason, a detailed gynecological evaluation as part of women’s health and menopause follow-up in Ankara is important in determining the most suitable treatment option for the patient. Systemic hormone replacement therapy may be suitable for some patients, while low-dose local vaginal treatments, non-hormonal medications, or lifestyle changes may be a more appropriate choice for others.

The form of medication used in menopausal hormone therapy should also be determined individually. Tablets, skin patches, gels, sprays, or local vaginal preparations may offer different advantages for different patient groups. For example, if vaginal dryness and painful intercourse are the main concerns, local vaginal estrogen therapy or other local options may be preferred instead of systemic treatment. In contrast, if hot flashes, night sweats, and sleep disturbances are prominent, systemic treatments may be more effective. What matters here is that the decision on hormone therapy during menopause is seen not as a standard prescription, but as a personal treatment process planned according to the patient’s symptoms, risks, and expectations.

The goal of menopausal hormone therapy is not to stop aging, prevent every disease, or give every woman the same treatment. The real goal is to correctly understand the complaints of a woman going through menopause, carefully evaluate her medical risks, and create a personalized menopause treatment plan that will safely improve her quality of life. For patients who would like information about menopause symptoms, hot flash treatment, night sweat treatment, vaginal dryness treatment, or hormone replacement therapy in Ankara, the treatment decision should be made through a detailed gynecological evaluation. If menopause symptoms affect daily life, sleep, sex life, or general health, hormone therapy and non-hormonal treatment options should be discussed together on an individual basis.

Menopausal Hormone Therapy (MHT): Frequently Asked Questions

What is menopausal hormone therapy?

Hormone therapy during menopause is a treatment used to manage hot flashes, night sweats, sleep disturbances, vaginal dryness, pain during intercourse, and certain bone health problems caused by declining estrogen levels during menopause. It can be administered systemically or locally in the vagina.

Is menopausal hormone therapy given to everyone?

No. MHT is not automatically given to every woman. A personalized decision is made by evaluating the severity of symptoms, age, time since menopause, whether the woman has a uterus, and risks such as breast cancer, blood clots, cardiovascular disease, stroke, and liver disease.

What is the best time to start menopausal hormone therapy?

In general, the benefit–risk balance is considered more favorable in women under 60 or within the first 10 years after menopause who have significant menopause symptoms and no contraindications. Starting at an older age or long after menopause requires more careful evaluation.

Why is progesterone needed in women with a uterus?

If systemic estrogen is given alone to women with a uterus, it can overstimulate the uterine lining and increase the risk of endometrial hyperplasia or cancer. For this reason, progesterone or a progestogen is added to protect the uterine lining.

Is progesterone needed in women who have had their uterus removed?

No, it is not needed. If the uterus has been removed, there is no endometrium, so estrogen alone can be used. However, special clinical situations such as a history of endometriosis or subtotal hysterectomy are exceptions.

Does menopausal hormone therapy cause breast cancer?

The risk depends on the type and duration of treatment and the individual’s baseline risk. A duration-dependent increase in breast cancer risk may be seen with combined estrogen and progesterone therapy. The risk profile of estrogen-only therapy is different. For this reason, the decision should be made based on a personal risk assessment.

Does menopausal hormone therapy increase the risk of blood clots?

Oral estrogens in particular can increase the risk of venous blood clots. Transdermal estrogen may be associated with a lower risk of blood clots in some patients. However, if there is a history of blood clots, thrombophilia, or high risk, systemic MHT should be evaluated very carefully.

Is vaginal estrogen the same as systemic hormone therapy?

No. Low-dose vaginal estrogen acts mainly on the vagina and lower urinary tract. Its systemic absorption is quite low. If there is only vaginal dryness, burning, painful intercourse, or genitourinary symptoms, local treatment is often sufficient.

Does hormone therapy during menopause cause weight gain?

Weight gain during menopause is often related to age, loss of muscle mass, metabolic changes, a slowing of the basal metabolic rate, sleep disturbances, and lifestyle. It cannot be said that hormone replacement therapy directly causes significant weight gain.

Does menopausal hormone therapy prevent heart disease?

Hormone therapy should not be started to prevent heart disease. The benefit–risk balance may be different, particularly in symptomatic patients in early menopause. However, MHT is not a treatment for primary or secondary cardiovascular prevention.

Is menopausal hormone therapy good for osteoporosis?

Hormone therapy during menopause can reduce bone loss and lower the risk of fractures. However, it is not started for everyone solely for osteoporosis. Osteoporosis risk, menopause symptoms, age, fracture risk, and other treatment options should be evaluated together.

How long can menopausal hormone therapy be used?

The duration is determined individually. Treatment is reviewed at regular intervals. The decision to continue, reduce the dose, or stop treatment is made by taking into account symptoms, age, risks, and the patient’s preferences. The same duration does not apply to every patient.

Should hormone replacement therapy during menopause be stopped suddenly or tapered off?

Both methods can be used. In some patients, tapering off may make the return of hot flashes more tolerable. Some patients can stop directly. The decision is made according to the symptoms and the patient’s preference.

Are there options for women who cannot use hormones?

Yes. Non-hormonal medications, lifestyle changes, cognitive behavioral therapy, vaginal moisturizers, lubricants, and certain local treatments can be used. Non-hormonal medication options for hot flashes and night sweats are increasingly available.

References:

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