Five Steps to Check Your Provider's Advice About MHT
Ask Dr. Jen
My doctor doesn’t want me to use hormone therapy, and I’m trying to find an independent medical source to help me understand why.
Via The Vajenda
What to do when your desire to take menopause hormone therapy (MHT) is at odds with your doctor’s recommendation (meaning they don’t think you should take hormone therapy)?
There are two possible answers. One possibility is that your doctor is not up to date on prescribing menopause hormone therapy (MHT), and there isn’t a valid reason for the denial.
The other possibility is that the medical care and recommendations are solid, and MHT may not be the best option for you. We don’t have any information on why our question writer received a “no” response from their physician, but when a medical provider says you aren’t a candidate for MHT, you should not only expect but deserve an explanation. In this scenario, as in every scenario in medicine, “no” doesn’t cut it. As a provider, when you know the data, an explanation should be easy. There is a lot of incorrect content regarding MHT on social media, which can lead people to think they could benefit from MHT when it may not be a good choice, so it’s always possible that someone went into their appointment misinformed about MHT. Basically, the misinformation can go both ways.
The best approach to sorting this out is knowledge about menopause, MHT, and other therapy options. This is why I created a Menopause Therapy Guide (click here for the table of contents). Knowledge helps you advocate for the best medical care, but also to check to ensure that you receive good care. To help you on this quest, and hopefully, the reader who asked this question, I will walk you through the five essential steps to determine if you are receiving quality care or not when it comes to starting MHT. And some tips on how to advocate for yourself when you aren’t getting the care you deserve.
Step One: Do You Have a Contraindication to MHT?
“Do no harm” is an essential concept in medicine. While the list of reasons we don’t recommend MHT is relatively short, it’s important to know:
Age: Starting MHT is not recommended if you are over 60 or more than 10 years from your last period; as for these people, there is an increased risk of stroke. Starting over age 65 is associated with an increased risk of dementia. We don’t have great data for those whose last period was 56 or 57 (hey, it happens), so the “10 years after the last menstrual period” is somewhat flexible here. If your last period was at age 57 and you decided that you wanted to start MHT at age 61, most providers would likely be okay with that, assuming there were no other risk factors for stroke.
Breast cancer: A personal history of breast cancer is considered a contraindication to menopause hormone therapy. The 2022 Menopause Society Guidelines state the following about a previous history of breast cancer:
Systemic hormone therapy is generally not advised for survivors of breast cancer, although hormone therapy use may be considered in women with severe VMS unresponsive to non hormone options, with shared decision-making in conjunction with their oncologists.
This guideline was written before the approval of fezolinetant, which is very effective for hot flashes. Read more about that drug here. I have been pleasantly surprised with how well it works.
Endometrial cancer or other hormone-responsive cancer: It’s hard to make a blanket statement because there are relatively few studies. While women with low-grade, early-stage endometrial cancer may be candidates for MHT (after consultation with their oncologist), for people with higher-grade or more advanced disease, there are greater concerns about tumor recurrence, so MHT is generally contraindicated. Some uterine sarcomas and some ovarian cancers may also be hormone-dependent, and caution will be needed here as well. You may have seen or read that “undiagnosed vaginal bleeding” is a contraindication to starting MHT. In this situation, your provider needs to rule out endometrial cancer as a cause of the bleeding before prescribing MHT.
Heart disease: A previous heart attack or known coronary heart disease means MHT is not recommended. An ASCVD (Atherosclerotic Cardiovascular Disease) score of 10% or higher is considered by most to be a contraindication to MHT (more below on how to calculate that score).
Stroke: A previous history of a stroke is also considered a contraindication. There may be some leeway here if the previous stroke was hemorrhagic, which is the result of a torn blood vessel, as it is an ischemic stroke that is the concern here.
Liver Disease: Advanced liver disease is a contraindication, and while the hormone therapy guidelines have a blanket statement about liver disease being a reason not to take MHT, not all liver diseases are the same. You can read more about that here.
Blood clots: Most guidelines consider a previous blood clot as a reason not to use MHT. For people with risk factors but no previous clot, the recommendations from different societies range from not recommended to maybe okay, but it is condition-dependent. This is a situation where care must be individualized. Read more about blood clots and MHT here. There is a new study out on risk factors for clots and MHT and I am working on another post on the subject, so stay tuned for more.
If you’ve finished this section and nothing applies to you (low cardiac risk, no breast cancer concerns, no previous clot, etc), then there are no obvious contraindications to MHT. However, if anything above applies to your situation, your provider may have a valid reason for not prescribing MHT, which is something to discuss further, including other options.
Step Two: Up To Date Testing
It is advisable to complete some questionnaires and tests before starting MHT.