MHT: is it for you? A 3-minute self-check

MHT stands for menopausal hormone therapy. You may still see the older label HRT (hormone replacement therapy): it's the same treatment, with an updated name.

At menopause, your ovaries make less and less estrogen. This hormone helps the hypothalamus (a small region of the brain) regulate your temperature ^[2]. When it drops, that internal thermostat misfires and triggers hot flashes and night sweats. MHT restores estrogen and settles the thermostat.

MHT comes in two main forms. If you still have your uterus, estrogen is paired with a progestogen (ideally micronised progesterone) to protect the womb lining ^[3]. After a hysterectomy (removal of the uterus), estrogen alone is enough.

The route matters as much as the molecule. Swallowed as a pill, estrogen passes through the liver first and raises clotting factors. As a gel or patch on the skin, it reaches the blood without loading the liver, with no rise in clot risk ^[5]. That's now the preferred route, especially with vascular risk factors.

The main indication fits in one sentence: menopause symptoms that affect your quality of life ^[3]. MHT is recommended first-line for bothersome hot flashes and night sweats, not as a last resort ^[4]. It remains the most effective treatment we have ^[13].

You may recognise yourself in one of these profiles:

• Hot flashes or night sweats that cut into your sleep, work or mood.
• Early menopause (before 45) or ovarian insufficiency (before 40): here MHT protects bone and heart, it's not just about comfort ^[4].
• Bone risk (family history, early menopause): estrogen slows bone loss and lowers fracture risk ^[6].
• Vaginal dryness, painful sex, recurrent urinary infections: this genitourinary syndrome affects up to half of postmenopausal women ^[7].

Genitourinary symptoms are treated with local estrogen (a pessary or cream), with minimal spread to the blood. This option stays open even when systemic MHT is contraindicated ^[7]. Unlike hot flashes, which eventually ease, this syndrome tends to worsen without treatment ^[7].

Many women think they've "missed the window". Here's what the term really means. Under 60, or within 10 years of menopause starting, the benefit-risk balance of MHT is favourable for symptoms and bones ^[2]. In France, the median age of menopause is 51 ^[1].

Timing matters because estrogen works better on arteries that are still flexible. One clinical trial showed estradiol slows atherosclerosis (plaque building up in the arteries) when started within six years of menopause ^[8]. Begun much later, that benefit fades.

One case flips the age logic: early menopause. If it happens before 40 or 45, MHT is usually recommended at least until the average age of menopause, to protect bone and heart ^[2].

So the "just wait it out" myth falls apart. Waiting isn't a strategy ^[2]. And past 60 or 10 years out, the door doesn't slam shut: the balance is weighed more carefully with your doctor, often through the skin or with local treatment. The question is always worth asking.

Some situations genuinely close the door to systemic MHT, and they're worth knowing ^[3].

The real contraindications include:

• a current or past breast cancer, or another hormone-sensitive cancer,
• a history of blood clots in the veins or lungs, or a stroke,
• active severe liver disease,
• unexplained vaginal bleeding, to be investigated before any decision.

These don't sentence you to endure everything. Certain medicines (paroxetine, venlafaxine, gabapentin) reduce hot flashes, and cognitive behavioural therapy eases how you experience them and your sleep ^[4]. Local estrogen often stays possible for genitourinary symptoms ^[3].

Many other barriers aren't real. "Too old": the window runs to 60. "A family history": it guides the assessment, it isn't an automatic verdict ^[4]. "MHT causes weight gain": the data show no weight gain from the treatment itself ^[11].

"It's too dangerous": the extra breast cancer risk exists but stays modest, depends on type and duration, and is smaller with estrogen alone ^[12]. Over 18 years, follow-up showed no rise in mortality ^[11]. And for clots, the transdermal route doesn't raise the risk, unlike the pill ^[5].