![Definitive Guide to Menopausal Hormone Therapy (MHT) in Australia [Previously Hormone Replacement Therapy (HRT)]](https://cdn.prod.website-files.com/67a429737852744b0f8481b6/6aacea45634db7f6d0630d84_menopausal%20hormone%20therapy%20australia.avif)
Menopausal hormone therapy, still widely known as hormone replacement therapy (HRT), is considered the most effective treatment available for vasomotor symptoms (hot flushes and night sweats) and genitourinary symptoms of menopause. It's also one of the most misunderstood, with a lot of outdated fear and conflicting information still circulating.
This article covers what MHT actually is, the different types available, and the real benefits and risks, based on current evidence and guidelines.
MHT replaces the oestrogen, and where needed progestogen and testosterone, that decline during perimenopause and menopause. It was previously called, and is still commonly referred to as, hormone replacement therapy (HRT). It treats menopausal symptoms including hot flushes (hot flashes), night sweats, and vaginal dryness, three of the most common symptoms of menopause.
Menopause is defined by your final menstrual period, diagnosed after 12 consecutive months without a period. Menopause occurs at an average age of 51 in Australian women, with a normal range of 45 to 55. Menopause before age 45 is classified as early menopause. Perimenopause is the transitional stage beforehand, typically through a woman's 40s, marked by irregular periods and shifting symptoms.
Menopause and MHT are generally assessed by symptoms and personal medical history rather than hormone blood tests. In women over 45, FSH and oestradiol levels don't reliably indicate menopausal status or how well MHT is working. Under 45, hormone testing is used to help rule out other causes of symptoms.
Declining oestrogen during perimenopause and menopause affects more than the symptoms above, it affects several body systems directly:
MHT falls into two categories: systemic therapy and local (vaginal) therapy.
Systemic oestrogen therapy treats menopausal symptoms throughout the body. It's available as pills, patches, or gels.
Women who still have a uterus need systemic oestrogen combined with a progestogen. Oestrogen alone increases the risk of endometrial cancer by overstimulating the uterine lining; progestogen protects against this. For women who've had a total hysterectomy, oestrogen-only MHT is generally used instead, since there's no uterine lining to protect. This differs for a subtotal (partial) hysterectomy, where some uterine lining may remain, meaning the oestrogen-only approach doesn't automatically apply. A history of endometriosis is also worth flagging to your doctor even after a total hysterectomy, since endometriosis tissue outside the uterus can still respond to unopposed oestrogen, and progestogen may still be needed to protect against this.
Combined MHT is either continuous (daily, generally with no bleeding once the body adjusts) or sequential (progestogen taken part of the month, producing a regular withdrawal bleed). The right choice depends on where a woman is in her menopause transition and her own preference around bleeding.
Around 27% of women still experience vaginal symptoms while on systemic hormone therapy. AMS guidance supports adding vaginal oestrogen on top of systemic MHT if this happens, rather than switching or stopping.
Low dose vaginal oestrogen treats vaginal and urinary symptoms only, such as vaginal dryness or recurrent urinary symptoms. It's available as oestrogen creams, pessaries (vaginal suppositories). It acts locally on vaginal tissue with minimal absorption elsewhere in the body, so it doesn't carry the systemic risks of pills, patches, or gels, and can generally be used long-term, including by women who can't use systemic MHT.
Prasterone is a vaginal preparation for moderate to severe menopausal vulvovaginal symptoms. It has weak oestrogenic and androgenic activity, so it isn't hormone-free. It isn't currently indicated or approved for breast cancer survivors in most countries.
Tibolone is a single tablet with combined hormonal activity. A combined oestrogen plus SERM (selective oestrogen receptor modulator) option is available that doesn't require added progestogen in women with an intact uterus. Older formulations such as conjugated equine oestrogens (conjugated oestrogen) are also still used by some prescribers, though micronised, body-identical hormones are generally preferred where available.
MHT reduces hot flushes, night sweats, and vaginal dryness, and can lower osteoporosis and fracture risk by protecting bone density. The following is based on Australasian Menopause Society (AMS) guidance:
Oral oestrogen is processed through the liver (liver metabolism), which is why it carries a higher clotting and stroke risk than transdermal oestrogen, which bypasses this first-pass liver effect. Oral oestrogen also isn't generally suitable for women with significant liver disease.
General cautions, and other health conditions a doctor would consider, include:
Needs specialist input, rather than a standalone caution:
Yes. Menopausal hormone therapy (MHT) is the more current clinical term, and hormone replacement therapy (HRT) is the older, still widely recognised name for the same treatment.
Not routinely. MHT is managed on how you feel, not on a number. Oestradiol levels vary widely between women on the same dose, correlate poorly with symptom relief, and are hard to interpret at all if you take oestrogen as a tablet, so there is no target level to aim for.
A level is occasionally checked if symptoms persist despite an adequate dose, to see whether you are absorbing your gel or patch properly. Testosterone is the exception and is monitored with blood tests to keep levels within the normal female range. Otherwise, follow-up focuses on your symptoms, blood pressure, and keeping breast and cervical screening up to date.
Hormones structurally identical to the ones the body naturally produces, such as micronised progesterone and oestradiol. Many TGA-regulated, pharmacy-dispensed MHT products are body-identical.
This differs from custom-compounded "bioidentical" preparations marketed outside standard pharmacy channels, which aren't TGA-regulated and lack the same evidence base and safety monitoring.
There's no set time limit, and the old advice to stop after five years is outdated. Australian and international menopause societies agree that no arbitrary limit should be placed on duration, and there's no age at which MHT must automatically be stopped. The decision is reviewed with your doctor at least yearly, weighing benefit against your own risk.
Duration does matter in one respect: the small increase in breast cancer risk with combined oestrogen and progestogen rises gradually with longer use, and is lower with oestrogen alone, which is exactly what the annual review is for. If your menopause happened before 45, MHT is recommended at least until around age 51, and vaginal oestrogen can be continued indefinitely.
Testosterone is sometimes used alongside MHT, though it can also be prescribed on its own. The only evidence-based indication in women is hypoactive sexual desire disorder, meaning low sexual desire that causes distress, and that evidence sits almost entirely in postmenopausal women.
There isn't currently enough evidence to support prescribing it for fatigue, low mood, or brain fog. Australia was the first country to approve a testosterone cream specifically for women (TGA, 2020), and it remains one of a small number of countries where this is approved including New Zealand and South Africa.
Trials in premenopausal and perimenopausal women are underway. Recent Australian research has also found that testosterone declines gradually with age rather than dropping at menopause, and that blood levels don't predict sexual desire, worth knowing given how often the opposite is claimed online.
This can indicate primary ovarian insufficiency (POI), which is assessed and managed differently from standard menopause care, and shouldn't be delayed.
This is assessed using the same FSH and oestradiol tests mentioned above, since a persistently high FSH and low oestradiol under 45 is what distinguishes POI from other causes of irregular periods.
For most healthy women, MHT started within 10 years of menopause or before age 60 has a favourable benefit-risk profile, and is considered safe and effective for menopausal symptoms by bodies including the Australasian Menopause Society. It isn't risk-free, and any decision should involve a full discussion of individual risks and benefits, including personal and family medical history, with a doctor.
Disclaimer: This article is general information only and doesn't replace personalised medical advice. If you're considering MHT (HRT), speak with your doctor about whether it's appropriate for you.
Steven is a specialist general practitioner, preventative health consultant, medical educator, healthcare entrepreneur and co-founder of Everlab. With 15+ years of clinical experience, and driven by his passion for preventive care outcomes, Steven is dedicated to personalised and innovative approaches to enhance well-being, extend human lifespan, and improve healthspan.
Aarielle is a specialist GP in preventative health and longevity, combining advanced screening with personalised care. She’s also an Accredited Skin Cancer Doctor and Lifestyle Medicine Practitioner.
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