MHT choice follows the Ws — who, what, when/how long, and why. Route and dose are tailored to symptoms and risk factors, not a fixed protocol. Exact strengths, brands and PBS listings change and sit at pbs.gov.au and the current product information — not reproduced in this summary.
The Ws of MHT prescribing
- Who: bothersome vasomotor, psychological or urogenital symptoms affecting quality of life, with no contraindication on screening.
- What: estrogen alone if no uterus; estrogen + progestogen if the uterus is intact, for endometrial protection. Vaginal estrogen alone if urogenital symptoms only.
- When: start once symptoms warrant treatment; reassess benefit & risk at least annually — no mandated stop age or fixed duration.
- Why: to relieve symptoms and support quality of life; bone protection is a secondary benefit, not the primary indication for most women.
Estrogen — route principles
- Transdermal (patch/gel) preferred over oral if VTE, migraine, liver or cardiometabolic risk factors — lower thrombotic risk.
- Oral is simplest and effective for lower-risk women without these factors.
- Vaginal estrogen treats urogenital symptoms with minimal systemic absorption; usually no added progestogen needed even long-term.
- Dose is titrated to symptom control, not by weight or a fixed schedule.
Progestogen — choice principles
- Always required with systemic estrogen if the uterus is intact, to protect the endometrium.
- Micronised progesterone is commonly preferred — favourable metabolic profile and may aid sleep.
- The levonorgestrel IUD gives effective endometrial protection plus contraception — useful in perimenopause.
- Match regimen to cycle status: cyclic progestogen with cyclic estrogen, continuous with continuous combined.
Special scenarios
POI (under 40) generally needs higher-dose, longer-duration MHT to around age 51, with bone & cardiovascular monitoring. Surgical menopause (especially under 45) is managed the same way unless contraindicated. BRCA1/2 or Lynch carriers and most breast cancer survivors need an individualised, specialist-involved discussion before starting MHT.
Follow-up & duration
- Review at 4–6 weeks, then 3 and 12 months, then annually while continuing therapy.
- No fixed stop date — continue while benefits outweigh risks for that individual, reviewed yearly.
- If stopping, taper over 3–6 months; restarting or switching formulation is reasonable if symptoms recur.
Safety
- Breakthrough bleeding in the first 3–6 months of continuous combined MHT is common and usually settles; new bleeding after this, or any unscheduled bleeding on a cyclic regimen, needs assessment.
- Don't stop MHT abruptly for a planned change — taper or cross-titrate to avoid a rebound surge in symptoms.
Red flags / refer
- No meaningful improvement despite an adequate trial and dose/route adjustment.
- BRCA1/2 or Lynch carrier requesting MHT — involve familial cancer genetics/gynae-oncology.
- Surgical or premature menopause under 45, or complex intolerance requiring specialist titration.
WH-05B v1.0 · Reviewed Jun 2026 · Review Jun 2027
Companion to WH-05A (assessment & risk stratification). Summary guidance only — doses & brands are not reproduced here. Verify against AMS guidance, the IMS 2024 White Paper and NICE NG23; confirm exact products at pbs.gov.au and menopause.org.au.
