Hormone therapy - menopause

A lack of estrogen or fluctuating estrogen levels can cause typical menopausal symptoms such as hot flashes, sleep difficulties, low energy, concentration difficulties, low mood, and muscle and joint pain. Estrogen relieves these symptoms effectively, but must be combined with a progesterone-like hormone in women who still have their uterus, because estrogen alone can overstimulate the uterine lining and increase the risk of bleeding disturbances and cancer.

Estrogen: In Norway, only estrogen that is identical to the body's own estrogen, called bioidentical estrogen, is used to treat menopausal symptoms. It is preferably given as a patch, gel, or spray because this does not increase the risk of blood clots and gives more stable levels than tablets.

Progesterone-like hormones: Protect the uterine lining.

Utrogestan (micronized progesterone): Bioidentical, lowest breast cancer risk.

Dydrogesterone: Synthetic, but also has a very good profile regarding breast cancer risk. Can be a good alternative for those who do not tolerate Utrogestan well.

Other progestogens: Somewhat higher risk of breast cancer.

Hormonal IUD (Mirena)

Research suggests that the more similar progesterone is to the body's own progesterone, the lower the breast cancer risk.

Patch: Most stable level, low risk of blood clots and stroke.

Gel and spray: Also provide steady delivery and low risk.

Tablets: More fluctuations and higher risk of blood clots and stroke.

The availability of patches has been unstable, but it is easy to switch between patch, gel, and spray.

Early menopause (before the ovaries have stopped completely)

The ovaries still produce some estrogen, so treatment must protect the uterine lining against both added estrogen and the body's own estrogen.

Two main methods:

1. Cyclical treatment

Mimics the menstrual cycle:

• 2 weeks of estrogen alone
• 2 weeks of estrogen + progesterone-like hormone. This gives monthly bleeding. It can later be extended to a 10-12 week cycle.

2. Hormonal contraception without estrogen

Most commonly used: Mirena hormonal IUD

Estrogen-free contraceptive pills such as Slinda or Cerazette can also work well

Contains synthetic progesterone

Protects the uterine lining continuously

Causes little or no bleeding

Provides reliable contraception (other menopause preparations do not). Good alternatives in early menopause.

Late menopause (after the ovaries have stopped)

Hormone levels are stable, and you can use:

• Combination preparations (estrogen + synthetic progesterone in the same patch/tablet), or
• Estrogen as patch/gel/spray + daily micronized progesterone (usually causes no bleeding, apart from some spotting during the first months).

Blood clots and stroke

Patch/gel/spray: No increased risk of blood clots, lower risk of stroke.

Tablets: Increase the risk. Caution is needed with smoking, high blood pressure, diabetes, high cholesterol, migraine with aura, biliary tract disease, or a family history of blood clots.

Breast cancer

The risk increases somewhat with combination treatment, but the increase is small:

• After 5 years: approx. 3 additional cases per 1000 women
• After 10 years: 6-8 additional cases
• After 15 years: 12-18 additional cases

It may be wise to have a mammogram before starting treatment if you are over 45, especially if you have a family history of breast cancer and have not had an examination for some time. It is also recommended to follow the screening program when using treatment that affects risk.

Lower risk of osteoporosis

Later onset of cardiovascular disease in women who start around menopause and use treatment for up to 10 years

Lower incidence of colon cancer with combination treatment

Treatment is individually tailored, and the goal is the lowest effective dose. Most people have symptoms for 3-7 years, but 10-15% have symptoms for more than 10 years. Most stop treatment before age 60, but can continue if needed.

Testosterone affects sexual desire, and some people experience better energy and focus, but this is not well documented. Before menopause, the ovaries produce 30-50% of testosterone; the rest comes from the adrenal glands.

There are no approved preparations for women in Europe, except in the United Kingdom, where AndroFeme was approved in 2025. This is because many countries' medicines agencies consider that there is too little safety data for use in women.

We therefore use preparations made for men and adjust the doses for women.

This treatment must be followed up carefully, both by the woman herself with regard to side effects and with regular blood tests.

Dry, sore mucous membranes are treated with local estrogen treatment, which does not affect breast cancer, blood clot, or stroke risk.

Preparations in Norway:

• Ovesterin (estriol) - cream or vaginal suppositories, available without prescription
• Vagifem (estradiol) - vaginal tablets, available without prescription or by prescription
• Gelisse (ultra-low-dose estriol) - prescription
• Intrarosa (DHEA) - converted to estrogen and testosterone in the cells, and may also increase sexual desire in some people
• All must be used regularly to have an effect. Local treatment can be combined with systemic treatment.

Hetetokter og kalde fakta - Helena Enger

Overgangskraft - Marianne Natvik

overgang.no

menopausematters.co.uk

womens-health-concern.org