We've discussed perimenopause on our blog before. It's the transitional time period leading up to menopause that can last up to 10 years. During this time, fluctuating hormone levels can contribute to symptoms such as irregular cycles, hot flashes, insomnia, mood changes, brain fog, vaginal dryness, and more.
There are many approaches available to help manage these symptoms, including lifestyle changes, nutritional support, supplements, and prescription therapies.
For some individuals, prescription menopausal hormone therapy (MHT) can provide significant benefit. In addition to improving quality of life and reducing symptoms, MHT may also help lower the risk of osteoporosis and cardiovascular disease in appropriate candidates.
As of March 1, 2026, many prescription hormone therapy medications are now covered under MSP in British Columbia. This means that eligible patients may be able to access these medications at no cost, even without extended health benefits. You can find the full list here:
https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/pharmacare/plans/national-pharmacare-plan-np/plan-np-menopausal-hormone-therapy
Understanding the Different Types of Hormone Therapy
Not all hormone therapy prescriptions are the same. The type of estrogen or progesterone used, and the way it is delivered, can influence efficacy, safety, and side effect profile.
A Naturopathic Doctor can make treatment recommendations that are individualized based on symptoms, medical history, risk factors, and patient preference.
Let's get into the options.
Oral vs Topical Estrogen
Estrogen can be prescribed in oral form (pills) or as topical preparations such as patches, creams and gels. While both can be effective for menopausal symptoms, topical estrogen is often preferred for many patients.
Why We Often Prefer Topical Estrogen
Topical estrogen is absorbed directly through the skin and bypasses the liver. This route helps to:
- Lower risk of blood clots and stroke compared to oral estrogen. This is especially important in older perimenopausal populations, as risk for blood clots and strokes increases with age.
- Less effect on triglycerides
Because of this, topical estrogen is often considered a safer option for patients with certain cardiovascular or metabolic risk factors.
Oral estrogen can still be an excellent option for some individuals depending on:
- Patient preference (some patients find patches and gels can cause skin irritation)
- Convenience
As with all medications, the best option depends on the individual patient.
Vaginal Estrogen
Vaginal estrogen is a low-dose, locally applied form of estrogen used specifically to address genitourinary symptoms of menopause, including vaginal dryness, irritation, discomfort with intercourse, and some urinary symptoms such as urgency and recurrent urinary tract infections.
Unlike systemic estrogen (patches, gels, or oral pills), vaginal estrogen works locally with minimal absorption into the bloodstream. This makes it a very well-tolerated option with a favorable safety profile, and it can be appropriate for many patients who are not candidates for systemic hormone therapy or who simply don't need it.
Vaginal estrogen can be used:
- On its own, for patients whose primary concern is genitourinary symptoms rather than hot flashes or other systemic symptoms
- Alongside systemic MHT, for patients who need both symptom relief and local genitourinary support
An important practical note: patients using low-dose vaginal estrogen do not typically require progesterone alongside it, even if they have a uterus, because systemic absorption is minimal. This is a meaningful distinction from systemic estrogen therapy.
Progesterone: Micronized Progesterone vs Medroxyprogesterone
For patients who still have a uterus and are using systemic estrogen, progesterone is prescribed alongside estrogen to protect the uterine lining.
While topical estrogen is preferred to oral estrogen, with progesterone it's the opposite. Topical progesterone isn't absorbed very well, so oral progesterone is preferred. There are several forms of progesterone available, but the two most commonly discussed are micronized progesterone and medroxyprogesterone acetate (MPA).
Micronized Progesterone
Micronized progesterone is often preferred because it is structurally identical to the progesterone naturally produced by the body (sometimes called a "body-identical" hormone).
Potential benefits may include:
- Better sleep support for some patients
- Lower impact on mood in sensitive individuals
- More favorable cardiovascular and breast health data compared to some synthetic progestins
Medroxyprogesterone Acetate (MPA)
MPA is a synthetic progestin that has been used for many years and remains appropriate for some patients.
However, some studies suggest that synthetic progestins may have a less favorable side effect profile in certain individuals compared to micronized progesterone, particularly regarding mood, weight, cardiovascular health, and breast tissue effects.
What Is Not Covered?
Compounded hormone therapy is not included under Plan NP. While some patients prefer compounded prescriptions because they allow for more individualized dosing options, these medications generally remain an out-of-pocket expense.
Final Thoughts
Hormone therapy is not one-size-fits-all, and the "best" prescription depends on a patient's symptoms, health history, preferences, and treatment goals. It is also not appropriate for everyone, MHT is generally not recommended for individuals with a history of hormone-sensitive cancers, unexplained vaginal bleeding, active liver disease, or certain cardiovascular conditions, among other contraindications. A thorough health history review is an essential first step.
For many individuals, menopausal hormone therapy can be a safe and effective tool for improving quality of life during perimenopause and menopause.
Naturopathic doctors are able to provide holistic care during this transitional phase, including reviewing your health history, ordering and interpreting bloodwork (at baseline and continually for appropriate monitoring), prescribing the appropriate medication and adjunctive care, and following up regularly to assess your response and make adjustments over time.
If you are experiencing menopausal symptoms and would like to discuss whether hormone therapy may be appropriate for you, speak with your healthcare provider to review your options and develop an individualized treatment plan.
