Hormone Therapy Prescribing

Menopausal hormone therapy (MHT) replaces declining ovarian estrogen to manage vasomotor symptoms (hot flashes, night sweats), genitourinary syndrome of menopause (vaginal atrophy, dyspareunia), and prevent osteoporosis. In women with an intact uterus, progesterone must be co-administered to prevent endometrial hyperplasia and cancer. The timing hypothesis from the WHI reanalysis demonstrates that MHT initiated within 10 years of menopause or before age 60 has favorable risk-benefit (reduced mortality, cardiovascular benefit, bone protection) vs initiating after age 60 or >10 years post-menopause (increased cardiovascular and VTE risk). Transdermal estradiol has lower VTE risk than oral (avoids first-pass hepatic clotting factor production). For genitourinary symptoms alone, low-dose vaginal estrogen is preferred — minimal systemic absorption, no concurrent progestin needed. Contraindications to systemic MHT: unexplained vaginal bleeding, active/history of breast cancer, active VTE/PE, active liver disease, known thrombophilia.