What kind of MHT is available in Ontario?
So you are ready to add Menopause Hormone Therapy into your day.. what will that look like?
The conversation around when to use which type of hormone therapy is extremely nuanced and much more complex that this blog post can realistically dive into. I want to use this post to just overview what these medications look like and how you may expect to take them.
Let's take a step back. Hormone therapy consists of 2 parts: estrogen and progesterone.
Progesterone Therapies Available in Canada
Progesterone is only REQUIRED if you have a uterus, as it's protects the lining from getting too thick and leading to health issue. The only ways to use progesterone for this type of protection is by taking an oral capsule or using an IUD.
Let me repeat:
The only way to take progesterone for uterine protection is with oral progesterone or an IUD. Topical progesterone will not protect your uterus from estrogen therapy.
Topical progesterone can be used for some women to help with sleep and mood, but this is when it is used WITHOUT estrogen. More often this is in cycling women.
Micronized progesterone, medroxyprogesterone, and norethindrone are the three oral progesterone products available. They each have their pro and cons. There are different dosing frequencies based on your needs and whether you are pre-menopausal, perimenopausal, or post-menopausal. Usually this means that you can expect to either take it continuously or for 12 days on/off.
The Mirena IUD is the only IUD that can be used for endometrial (uterine lining) protection. It is approved for use for 5 years before needing to be changed to maintain protection. If you've used an IUD before you may remember that they can last for longer than this (just approved for 10 year usage!). However, this has NOT translated over for use with MHT. Until that guideline changes, expect to replace it every 5 years or so. And honestly, I've seen some women start noticing changes between year 4 and 5 that could indicate a need to be changed before that specific 5 year anniversary, so I don't expect the recommendation to change any time soon.
Estrogen Therapies Available in Canada
Estrogen is going to be able to be taken in 6 forms: oral, ring, gel, patch, suppositories, or cream. And at the end of the day, some people absorb/respond better to one form over another. This is the biggest deciding factor on which therapy is right for you. Some women don't get relief with oral, or others don't get relief with the gel, etc. So there is always going to be some form of assessment and trial and error when you start a therapy like this to find the best dose and route for you. Please expect this!
Oral estrogen, such as premarin (conjugated equine estrogen - CEE) or estrace (estradiol) are a pill that's taken once a day every day. There are some pills like Activelle or Angeliq that are combined estrogen and progesterone as well.
Patch estrogen is estradiol. There are 4 different brands. Estradot, generic, oesclim are all placed twice a week. Climara patch is changed weekly.
The two gels in Canada are Estrogel and Divigel. The gel comes in a pump (estrogel) or packet (divigel) so that you get the same dose every time, and absorbs in about 5 minutes. You rub it into the outside skin of your arms, from your shoulder down to your wrist.
Vaginal estrogen includes the ring, suppositories and creams. These forms of estrogen are helpful for local, vaginal concerns that happen around menopause. These aren't indicated if your main concern is hot flashes but are great when you have incontinence, itching, pain on intercourse, or dryness. Ring estradiol, the Estring, is inserted vaginally every 3 months. This is NOT an IUD, it stays in the vaginal canal and its ring shape lets it sit around the cervix. Vagifem is a Suppository tablet that is used once a day for 14 days and then reduced to 1 table twice a week. Creams can be really helpful for vaginal concerns because they spread really nice on the tissue here and can help quicker. But they are a daily application and some people find them messy. Estragyn is the only estrone on that market and used daily for 3 weeks and then with a one week break before repeating. Lastly there is also compounded estriol (no pre-made product on the market yet unfortunately) that is also really helpful for vaginal symptom. This is applied daily for a couple weeks and then reduced to twice weekly.
Is one form better than the other?
Ehhhh.. again this refers back to that nuanced piece that I mentioned at the start of this post. Long term vs short term vs cardio metabolic vs breast vs all these factors come into play. Overall, I would say that in terms of where would I start.. I would probably start with micronized progesterone and transdermal estradiol. The research shows that this has the best long term safety profile and most positive effects on things like heart and bone health. But if you don't get benefit from these forms it's not to say that you shouldn't try any of the other ones, ya know? This is my most common starting point.
I hope this article was helpful for you to know what to practically expect when starting up on menopause hormone therapy.
