Hormone replacement therapy (HRT), also called menopausal hormone therapy, is one of the most misunderstood treatments in modern medicine. In the decade after Women’s Health Initiative 2002, many women were refused HRT by fearful doctors. Current evidence is clearer - and more nuanced.
If you are still unsure whether your symptoms fit perimenopause, menopause or postmenopause, start with What is Menopause? before comparing treatment options.
What HRT is
HRT replaces estrogen (and sometimes progesterone) lost after menopause. Goal: reduce symptoms and prevent some long-term consequences of estrogen deficiency.
Main types
Estrogen-only - for women without a uterus (post-hysterectomy)
Estrogen + progesterone - for women with a uterus. Progesterone protects the endometrium from hyperplasia or cancer that unopposed estrogen could cause.
Tibolone - synthetic with estrogenic, progestogenic, androgenic effects. Option for some women with low libido.
Delivery methods
| Method | Common options | Notes |
|---|---|---|
| Transdermal patch | Estradot, Climara | Often first choice - lower clot risk |
| Transdermal gel | Oestrogel | Apply morning, easy dose adjustment |
| Oral tablet | Premarin, Estrofem | Slightly higher clot risk |
| Vaginal ring (systemic) | Femring | Replaced every 3 months |
| Local vaginal estrogen (genitourinary syndrome of menopause only) | Vagifem, Premarin cream | Minimal systemic absorption |
If your main symptoms are dryness, burning, recurrent urinary tract infection or pain during intimacy, use the vaginal dryness quick-start plan before discussing local estrogen options.
What evidence says
Benefits (strong evidence)
Vasomotor symptoms: North American Menopause Society 2022 - HRT reduces hot flash frequency and severity more than anything else. Typically 75%+ reduction.
Genitourinary syndrome of menopause (GSM): Local vaginal estrogen may be effective for selected patients for dryness, dyspareunia, recurrent urinary tract infection.
Bone: Prevents bone loss and reduces fracture risk by 30-40%.
Mood: For women with mood lability tied to hormone cycles, HRT can improve mood. Not first-line for clinical depression.
Benefits (emerging evidence)
Heart: Started within 10 years of menopause, HRT may have cardioprotective effects (Manson et al. 2017). Started later (>10 years post-menopause or >60), risk increases. This is the “window of opportunity hypothesis”.
Cognitive: Complex evidence. Early start may protect; late start may worsen.
Risks
Breast cancer: Women’s Health Initiative Rossouw 2002 showed elevated risk in women >60 on combined HRT. Long-term follow-up Manson 2017 shows in younger women the absolute risk increase is small - about 1 additional case per 1000 women yearly after 5 years of combined use.
Estrogen-only does not show increased breast cancer risk in Women’s Health Initiative follow-up.
Blood clots in the leg or lung: Slight rise with oral estrogen. Transdermal patch or gel may have a lower clot-risk profile than oral estrogen for selected women, but the choice still needs clinician review.
Stroke: Slight rise with oral, especially in older women.
Endometrial cancer: Estrogen without progesterone in women with uterus - risk very high. Hence combination required.
Who’s a candidate
Good candidates:
- Severe hot flashes / night sweats
- Early menopause (under 45) - HRT recommended until 50
- Premature ovarian insufficiency (under 40) - HRT often recommended after clinical review
- Vaginal dryness unresponsive to moisturiser/lubricant
- Bone loss (osteopenia/early osteoporosis) wanting alternative to bisphosphonate
- Mood swings strongly linked to cycle
Caution / relative contraindications:
- Personal breast cancer history - discuss with oncologist
- Personal history of blood clots in the leg or lung - patch safer than oral
- Uncontrolled hypertension
- Migraines with aura - patch/gel preferred
- Active liver disease
Absolute contraindications:
- Undiagnosed vaginal bleeding (investigate first)
- Active breast cancer
- Active endometrial cancer
- Severe liver disease
”Bioidentical” versus synthetic
“Bioidentical” means same molecular structure as human hormones.
Regulated bioidenticals:
- 17-beta estradiol (patch, gel, oral) - bioidentical
- Micronised progesterone (Utrogestan, Cyclogest) - bioidentical
Both available in Malaysia and standard choice.
Compounded bioidentical (pharmacy custom mixes):
- Sold by some private pharmacies
- Not regulated like licensed drugs
- Dosing consistency questionable
- Often more expensive
- No proven safety advantage over registered bioidenticals
The North American Menopause Society 2022 and the Obstetrical and Gynaecological Society of Malaysia do not endorse compounded bioidentical as first-line.
HRT in Malaysia: practicalities
Cost
- Private clinic first visit: confirm the current fee directly with the clinic
- Patch/gel monthly: RM150-300
- Micronised progesterone monthly: confirm the current price with the clinic or pharmacy
- Total monthly: RM200-450
Government hospitals
HRT available at major government hospitals (HKL, PPUM, major state hospitals) with referral. Much lower cost but waiting times 4-12 weeks for specialist clinics.
Insurance
Most Malaysian health insurance doesn’t cover HRT as outpatient. Check your policy. Some cover HRT for premature ovarian insufficiency.
Follow-up
Annual or 6-monthly visits for:
- Symptom assessment
- Blood pressure
- Breast exam (mammogram every 2 years)
- Abnormal bleeding flag
Starting HRT: what to expect
Months 1-2: symptoms may still be inconsistent as body adjusts. Some women feel better quickly; others need dose adjustment.
Month 3: most women feel significant relief from hot flashes and sleep.
Common side effects:
- Unexpected bleeding in first months (cyclical)
- Breast tenderness
- Headache (especially first week)
- Bloating (especially with progesterone)
These usually resolve in 2-3 months or with dose adjustment.
When to stop
No fixed age limit. Annual reassessment:
- Do symptoms return if dose reduced?
- Have personal risk factors changed?
- Do you want to continue?
When stopping, tapering (gradually reducing dose) is better than abrupt stop to avoid rebound hot flashes.
Non-hormonal options (when HRT isn’t suitable)
- Certain antidepressants - paroxetine, venlafaxine, escitalopram for hot flashes (off-label)
- Gabapentin - especially for night sweats
- Fezolinetant (if available in Malaysia in future)
- Soy isoflavones for mild symptoms
- Cognitive behavioural therapy (CBT) for hot flashes - emerging evidence
- Lifestyle - supportive, not replacement
See related guides:
Questions for your doctor
- Am I a candidate based on my profile?
- What options do you recommend (patch, gel, oral)?
- What are my personal risk factors?
- What monitoring will be required?
- Realistic monthly cost?
- What signs should I call you about urgently?
HRT is a personal decision made with a specialist who understands your profile. Don’t let outdated Women’s Health Initiative 2002 fear-mongering keep you from an effective treatment option.
