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Menopause accompanies a significant stage of a woman's life. Physiological hormonal changes affect almost all organs and organ systems. A significant proportion (about 25-30%) of menopausal women suffer from severe, quality of life-deteriorating symptoms related to estrogen deficiency, which require treatment for a shorter or longer period. The most effective way to treat the set of menopausal symptoms is menopausal hormone therapy. The alternative options for symptom reduction are limited, and the possible treatment methods are less effective and less studied.

Principles of Menopausal Hormone Therapy (MHT):

• Treat moderate and severe symptoms of estrogen deficiency,
• Carefully consider indications and contraindications,
• Treat with the smallest effective dose,
• It is advisable to re-evaluate the indications for MHT annually, and to provide patient-centered care.

When is Menopausal Hormone Therapy (MHT) recommended?

• To treat symptoms of menopause syndrome caused by estrogen deficiency;
• For the prevention of postmenopausal osteoporosis, to stabilize developed osteopenia or osteoporosis;
• In the case of irritability, sleep disorders, and mild forms of depression;
• To alleviate complaints caused by atrophy of the urinary and genital organs following menopause.

When is Menopausal Hormone Therapy not recommended?

• Breast cancer: The European Drug Safety Committee (CSM) does not recommend MHT for all women who have been diagnosed with breast cancer.
• Endometrial carcinoma. The stage of the disease limits treatment options.
• Thromboembolic diseases. Almost all forms of estrogen treatment are more or less predisposing to the development of thromboembolic diseases.
• In case of ischemic heart disease (IHD), it is not advisable to start or continue MHT.

Complications of Menopausal Hormone Therapy:

Like all drug treatments, menopausal hormone therapy can also have complications. With adherence to the rules of MHT application, there are relatively few complications, but bile complaints are more common in a dose-dependent manner.

The risk-increasing effects of Menopausal Hormone Therapy:

- Breast Cancer

• Properly dosed MHT only slightly increases the density (glandularity) of the breast.
• In the first 5 years of treatment, the risk increase is extremely small.
• If MHT starts years after the onset of menopause, breast cancer may decrease in the first 5 years.
• 3-5 years after stopping MHT, the incidence of breast cancer does not increase.
• A smaller increase in the risk of breast cancer is more likely to be observed in women with a smaller body mass index.
• During hormone therapy only with estradiol (only after hysterectomy), the risk of breast cancer decreases.

- Cardiovascular risk

• Basic research and observational studies suggest that MHT may reduce the frequency of cardiovascular events.
• If MHT started in late postmenopause, the cardiovascular risk increased, typically only in the first year.
• Tibolone treatment does not increase cardiovascular risk.
• Only estrogen MHT (after hysterectomy) reduced the risk of heart attack.

- Venous thromboembolic complications

• Both endogenous or externally supplied estrogen, both in fertile age (pregnancy, birth control pill) and in menopause, increases the tendency for thrombosis. This is enhanced by the genetic risk of thrombophilia, obesity, surgical interventions, prolonged bed rest, and in menopause, the age-related increase in thrombosis tendency.
• Transdermal MHT does not increase the occurrence of thromboembolism.

- Stroke

• Tibolone treatment increases the risk of stroke in older, but not younger postmenopausal women.
• The stroke risk of healthy postmenopausal women may increase by a third due to orally administered MHT.
• Low-dose transdermal estrogen treatment does not increase the risk of stroke.

- Uterine cancer

• Uncombined MHT increases the frequency of uterine cancer, so we combine estrogen treatment with progestogens, or with the progesterone itself.
• With periodically given progestogens, estrogen does not increase the risk of uterine cancer, continuous combined treatment even reduces it.
• Long cycle (induction of bleeding every 3 months with 14 days of progestogens) MHT probably does not increase the risk of uterine cancer.

Forms of MHT application:

• the tablet is easier to apply, but has more side effects, the absorption is unpredictable, so the achieved serum estrogen levels differ individually;
  
  
• transdermal or vaginal applications result in significantly less estrogen entering the circulation by bypassing the liver, the risk of thrombosis is negligible.
  
  
• intrauterine devices: only for the intake of progestogens.

Personalized Therapies

Menopausal Hormone Therapy (MHT) should be prescribed only after analyzing the patient's personalized risk-benefit, based on the results of medical examinations. In cases of mild vegetative symptoms of menopause syndrome, the first suggestion is lifestyle change, weight management with planned physical exercise, dietary modifications, and stress reduction.

If the symptoms persist or worsen, and instrumental examinations justify and do not contraindicate it, MHT can be prescribed with the patient's informed consent. The appropriateness of the treatment should be reviewed annually and a joint decision about continuation should be made with the patient.

The principle of therapy is that the patient should receive the smallest effective dose for the duration of the symptoms or complaints. Most treatments end within 5 years. Once the menopausal symptoms have ceased, it is advisable to gradually phase out the Menopausal Hormone Therapy.

Supplementary, Alternative Pharmacological Treatment Methods

Phytopharmaceuticals, phytoestrogens, isoflavones, as well as vitamins (E and D) and minerals (primarily calcium, magnesium) are widely available in the form of over-the-counter medicinal products. Their spectrum of effects and side effects are not yet fully clarified. Among the plant extracts, the most studied, widely used, and available in standardized preparations is the extract of Cimicifuga racemosa. Kava-kava (Piper methysticum), containing phytoestrogens, can be harmful to the liver and is not marketed in our country. Red clover (Trifolium pretense) has mild estrogenic effects, Dong quai root (Angelica sinensis), and Ginseng root (Panax ginseng) are used for various menopausal symptoms, but – according to randomized studies – are ineffective for hot flashes.
The most commonly used pharmaceutical alternatives to estrogen treatment are clonidine, gabapentin, and venlafaxine, whose effectiveness in alleviating hot flashes and sleep disorders has been confirmed in smaller controlled trials. Known side effects include nausea, libido decrease, and sleep disorders. Their effectiveness never reaches that of estrogens -
There are promising publications on the effectiveness of acupuncture, and various methods of electrostimulation performed with different devices.

Tea Mixtures

The composition and purity of tea mixtures are difficult to verify. They may contain phytoestrogens, the long-term effects of which are unknown. They should be used with caution, primarily due to the risk of kidney damage.

If you would like to learn more about the treatment options, make an appointment and meet our gynecologist specialist, Dr. Károly Sándor Tóth!