Surgical Menopause New Zealand Trust

On this page: Understanding Hormone Replacement Therapy (HRT) HRT: Part of a Holistic Solution Types of Hormones Systemic HRT: Comprehensive Relief for Whole-Body Symptoms Estrogen Therapy Options Progesterone/Progestin Options Combined Estrogen/Progestin Options Testosterone Options Local HRT: Targeted Relief for Specific Symptoms Local Estrogen Vaginal Options Local DHEA Vaginal Option Understanding the Risks Side Effects of HRT References

Understanding Hormone Replacement Therapy (HRT)

Hormone Replacement Therapy (HRT) – also known as Menopausal Hormone Therapy (MHT) – is designed to boost the levels of estrogen, progesterone, and sometimes testosterone, hormones no longer produced after menopause. It’s especially important for women experiencing surgical menopause or primary ovarian insufficiency (POI), helping to replace essential hormones their bodies have lost.

HRT: Part of a Holistic Solution

Hormone Replacement Therapy (HRT) is a valuable tool for managing the symptoms of surgical menopause, but it’s important to recognise that it is not a perfect substitute for the body’s natural hormones. While HRT can significantly alleviate many symptoms, it may not entirely eliminate them. 

Every woman’s experience with HRT is unique, and some may continue to experience symptoms despite taking HRT. Additionally, it may take time and multiple attempts to find the right formulations and dosage that work best for you. This highlights the need for ongoing research to refine and optimise HRT treatments, ensuring they are as effective as possible for all women.

HRT is only one component of a holistic approach to managing surgical menopause. To achieve the best possible outcomes, HRT should be complemented with healthy lifestyle choices. This includes:

• Maintaining a balanced diet
• Engaging in regular physical activity
• Managing stress
• Getting enough sleep
• Staying connected with a support network 

Incorporating these practices can enhance the benefits of HRT and help you navigate the challenges of surgical menopause more effectively.

For details on wellness strategies, check the Long-Term Health and Complementary Treatments sections.

Types of Hormones

Hormone Replacement Therapy (HRT) primarily involves three key hormones that play critical roles in reproductive health and overall well-being:

Estrogen (Oestrogen)

Estrogen is a vital hormone produced by the ovaries that influences many bodily functions. It interacts with estrogen receptors throughout the body, making it crucial not only for reproductive health but also for the proper functioning of other systems.

In the context of HRT, estrogen replacement can help alleviate the symptoms of menopause, such as hot flushes, night sweats, and vaginal dryness. Estrogen also plays a key role in maintaining bone health and density, reducing the risk of osteoporosis. Additionally, estrogen has been shown to have positive effects on cardiovascular health, helping to protect the blood vessels and potentially lowering the risk of heart disease.

The four main naturally occurring estrogens in women are:

• Estrone (E1): Primarily produced in the ovaries, adrenal glands, and fat tissue, playing a significant role in the menstrual cycle and pregnancy.
• Estradiol (E2): Also called 17β-estradiol, the most abundant and potent estrogen in premenopausal women, essential for reproductive health and multiple other bodily functions.
• Estriol (E3): The least potent of the estrogens, primarily active during pregnancy.
• Estetrol (E4): A natural estrogen produced by the fetal liver during pregnancy.

Progesterone

Progesterone is released by the ovaries after ovulation, preparing the uterine lining (endometrium) for implantation and sustaining pregnancy. If pregnancy does not occur, progesterone and estrogen levels fall, resulting in menstruation.

Progesterone is an essential component of HRT for women who have not had a hysterectomy. It can also sometimes be necessary for women with severe endometriosis even after hysterectomy. By helping to balance the effects of estrogen received through HRT, progesterone can play a role in preventing the recurrence of endometriosis symptoms. This makes progesterone an important part of HRT regimens for those managing both menopause and endometriosis. 

Progesterone has also been found to have a beneficial effect on sleep and mood, and it may be included in HRT regimens to help manage sleep disturbances associated with menopause, even post-hysterectomy. It’s important to be aware that some women may experience progesterone intolerance.  

Testosterone

Although often associated with men, testosterone plays a significant role in women’s health, contributing to libido, bone density, and overall well-being. In women, testosterone is produced in the ovaries and adrenal glands. Testosterone can be prescribed to address low libido or Hypoactive Sexual Desire Disorder (HSDD), conditions that are particularly common among women in surgical menopause, as the removal of the ovaries leads to a substantial reduction – about 50% – in testosterone levels.

Systemic vs. Local HRT Systemic HRT: – Designed to affect the entire body by delivering hormones into the bloodstream.  – Delivered via pills, patches, or gels for full-body relief – hot flushes, night sweats, mood swings, and bone density loss. The choice of approach is tailored to each individual’s situation. – Transdermal (patch/gel) preferred for stable hormone levels and reduced clot risk. Local HRT: – Focuses on treating specific symptoms related to vaginal and urinary health, Genitourinary syndrome of menopause (GSM).  – Applied directly to the affected area using creams, rings, tablets, or pessaries.  – Particularly effective for addressing issues without significantly affecting hormone levels in the rest of the body. Many women benefit from combining both approaches for targeted and broad symptom relief.

Systemic HRT: Comprehensive Relief for Whole-Body Symptoms

Systemic HRT involves administering hormones – typically estrogen, progesterone, and sometimes testosterone – in a way that allows them to circulate through the bloodstream and impact multiple organ systems. This approach can be delivered orally or transdermally, ensuring comprehensive relief from a wide range of menopausal symptoms. The choice of approach is tailored to each individual’s situation.

Transdermal Approach

The transdermal approach for estrogen is typically the most recommended. It delivers hormones through the skin, via patches, gels, or creams, providing a steady release of estrogen into the bloodstream. This method is preferred for several reasons:

• Lower Risk of Blood Clots: Transdermal HRT bypasses the liver, reducing the risk of blood clots and other cardiovascular issues compared to oral HRT.
• Stable Hormone Levels: Transdermal options offer more consistent hormone levels, which can help in better managing menopausal symptoms. Although some women experience a steadier dose on oral tablets. 
• Customisation: These formulations can be tailored to individual needs, with varying doses and combinations available.There can be significant differences in estradiol levels among women using the same transdermal preparation, sometimes varying by as much as ten times. This means it can be hard to predict how one woman will respond to the same dose as another.

That being said, there can be significant differences in estradiol levels among women using the same transdermal preparation, sometimes varying by as much as ten times. This means it can be hard to predict how one woman will respond to the same dose as another.

The effectiveness of transdermal estrogen depends on how well the hormone can pass through the skin. Factors like diet, alcohol intake, drug use, smoking, physical activity, and stress can quickly change how the body absorbs and processes these hormones. Additionally, blood flow in the skin can vary throughout the day, often increasing in the evening, which can enhance absorption.

Because of these factors, transdermal estrogen might not be the best option for everyone. If there are no specific risk factors—like obesity or a history of blood clots—oral estrogen could also be a good choice. Ultimately, your healthcare professional will review with you what is the best HRT option for your situation.

Choosing the Right Option

The type and dose of HRT will be determined by the following factors:

• Patient preference
• Uterine presence or absence
• Symptom type and severity
• Comorbidities (or coexisting conditions, which refer to the presence of two or more medical conditions occurring at the same time).

Estrogen Needs in Surgical Menopause

Women in surgical menopause often require higher estrogen doses to relieve symptoms and maintain bone health. A serum estradiol level above 250 pmol/L is typically targeted, though some women may need even more to feel well.

In natural menopause, standard doses include:

• Oral: 1-2 mg estradiol
• Patch: 25-50 mcg
• Gel: 1-2 pumps of Estrogel

In contrast, a common physiological dose for surgical menopause might include:

• Oral: 2-4 mg estradiol
• Patch: 75-100 mcg
• Gel: 3-4 pumps of Estrogel (0.75 mg per pump)

While many younger women tolerate these higher doses well, data on long-term use of doses above the official recommendations is limited. Still, many women with surgical menopause find these higher doses necessary. If symptoms remain despite high dosing, changing to a different form of estrogen might help.

Balancing Effectiveness & Side Effects

Some women experience difficulty tolerating higher doses due to side effects like breast tenderness or migraines. In such cases, it’s important to personalise the treatment, balancing benefits, risks, and side effects. Starting with lower doses can help assess tolerance before gradually increasing to an optimal level.

When to Check Hormone Levels

Routine blood tests aren’t usually required. However, checking estradiol levels may be helpful if:

• Symptoms persist 6-12 weeks after starting HRT
• Side effects continue after 6-12 weeks
• The person has premature ovarian insufficiency (POI) or early menopause and isn’t responding to treatment, especially if bone health is a concern (e.g. after a DEXA scan)

Estrogen Therapy Options

Progesterone/Progestin Options

For women who still have their uterus, HRT also includes progesterone (and synthetic progestins to complement estrogen therapy), but even without a uterus, many women opt to use progesterone for its calming effect that can support sleep. It’s important to note that some women experience progesterone intolerance. The available progesterone/progestin options in New Zealand are fully funded. They may be available under brand names or as generics, and include the following options:

• Provera – medroxyprogesterone acetate (tablet)
• Primolut N – norethisterone (tablet)
• Mirena coil – levonorgestrel (intrauterine device)
• Utrogestan – micronised progesterone (capsule)

FULLY FUNDED PROGESTERONE/PROGESTIN OPTIONS

PROVERA Type: Oral progestin (tablet) How it works: Contains medroxyprogesterone acetate, a synthetic progestogen. Used alongside estrogen in HRT to protect the uterine lining. Available in 2.5 mg, 5 mg, and 10 mg doses taken daily. Cost: Fully funded. Pros: – Flexible dosing options – Widely available Cons:  – Not body identical – May cause side effects such as bloating, mood changes, or breast tenderness —————————————————————- PRIMOLUT N Type: Oral progestin (tablet)  How it works: Contains norethisterone, a synthetic progestogen. Taken daily with estrogen to protect the uterus. Pros:  – Convenient oral option – Readily available Cons:  – Not body identical – May cause headaches, mood changes, or spotting —————————————————————- MIRENA COIL Type: Intrauterine system (IUS)  How it works: A T-shaped device inserted into the uterus by a healthcare provider. Releases a steady low dose of levonorgestrel (a progestin). Lasts for up to 5 years when used with estrogen therapy. Cost: Device is fully funded; insertion is not funded. Pros:  – Long-lasting (up to 5 years) – Low maintenance once inserted Cons:  – Requires insertion by a healthcare provider – Insertion may be uncomfortable or painful – Upfront insertion cost not covered —————————————————————- UTROGESTAN Type: Oral or vaginal progesterone (capsule) How it works: Contains 100 mg of micronised progesterone (body identical). Taken with estrogen for uterine protection. Can be swallowed or inserted vaginally. Cost: Fully funded. Pros:  – Body identical hormone – Can be taken vaginally to reduce side effects – Often helps with sleep when taken at night Cons:  – May cause dizziness, fatigue, or digestive upset in some women – Contains sunflower oil and soy (not suitable for those with allergies)

Combined Estrogen/Progestin Options

These options combine estrogen with progestin, a synthetic form of progesterone. They may be available under brand names or as generics, and the ones available in New Zealand are:

• Triquestrens – estradiol and norethisterone acetate (tablet)
• Kliovance – estradiol hemihydrate and norethisterone acetate (tablet) 
• Kliogest – estradiol and norethisterone acetate (tablet)

PARTIALLY FUNDED COMBINED ESTROGEN/PROGESTIN OPTIONS

TRIQUESTRENS Type: Cyclical combined HRT (tablet).  How it works: Contains estradiol 2 mg and norethisterone acetate 1 mg. Taken in a cycle to mimic natural hormone fluctuations. Cost: Partially funded. Pros:  – Provides cyclical progestogen, supporting uterine health – May suit women who prefer a more natural hormonal rhythm Cons:  – Less convenient than continuous options – May cause mood changes, bloating, or breast tenderness —————————————————————- KLIOVANCE Type: Continuous combined HRT How it works: Contains estradiol hemihydrate 1 mg and norethisterone acetate 0.5 mg. Taken once daily with no hormone-free interval.  Pros:  – Once-daily dosing. – Continuous dosing may reduce breakthrough bleeding over time Cons:  – Possible side effects: headaches, breast tenderness, mood changes, and gastrointestinal upset.  – Not suitable for some women with hormone-sensitive or cardiovascular conditions. —————————————————————- KLIOGEST Type: Continuous combined HRT  How it works: Contains estradiol 2 mg and norethisterone acetate 1 mg. Higher estrogen dose than Kliovance. Taken once daily. Pros:  – Once-daily dosing – Higher estrogen dose may be more effective for symptom control Cons:  – Possible side effects: headaches, breast tenderness, bloating, and mood changes – Not recommended for women with certain health conditions, including hormone-sensitive cancers

Testosterone Options

Testosterone therapy can effectively boost libido, energy levels, and mood in women with low testosterone. Additionally, it may enhance muscle strength and bone density. It’s important to monitor blood levels before starting treatment and regularly thereafter, as well as to track symptom improvement. Care should be taken to avoid excessively high levels (above typical female physiological ranges), as these can lead to irreversible side effects, such as voice changes. The testosterone options available in New Zealand are:

• Fully Funded: Testogel (gel).
• Not Funded: Androfeme (cream).

FULLY FUNDED TESTOSTERONE OPTION

TESTOGEL Type: Gel (male product) How it works: Pump dispenser. Women usually use a quarter of a pump daily, requiring careful measurement. Cost: Fully funded.  Pros:  – No cost – Readily available Cons:  – Dosing is imprecise. – Not formulated for women.  – Some doctors reluctant to prescribe – Potential side effects: acne, mood swings, body hair growth, voice change

NOT FUNDED TESTOSTERONE OPTION

ANDROFEME Type: Cream (female product, licensed in Australia) How it works: Cream and syringe.  Cost: Around $153 per 50ml tube (avg. 3 months use) Pros:  – Specifically designed for women – Easy to apply and adjust Cons:  – Not funded (Support the petition to get it funded here) – Higher upfront cost

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Local HRT: Targeted Relief for Specific Symptoms

Local (or topical) hormone replacement therapy (HRT) is specifically targeted to treat localised symptoms, particularly those affecting the vaginal and urinary areas. Local HRT delivers a lower dose of hormones directly to the affected area, typically through creams, vaginal tablets, rings, or pessaries. This localised treatment helps to restore the health of vaginal tissues without significantly affecting hormone levels throughout the rest of the body, making it a suitable option for those who need relief from specific symptoms without the broader impact of systemic therapy.

Local Estrogen Vaginal Options

Estrogen vaginal therapy is a localised treatment that delivers low doses of estrogen directly to the vaginal tissues. The options available in New Zealand are:

• Fully Funded: Ovestin (cream and pessary).
• Not Funded: Vagifem (tablet with applicator) and Estring (ring inserted).

FULLY FUNDED LOCAL ESTROGEN VAGINAL OPTIONS

OVESTIN. Cream that contains estriol.  Pros: Can be applied externally around the urethra, clitoris, and labia to help prevent and reverse tissue atrophy. Provides localised treatment to alleviate symptoms effectively. Cons: May feel messy during application, and some women may have reactions to the preservatives contained in the cream. —————————————————————- OVESTIN. Pessary that contains estriol.  Pros: Contains no preservatives, which may reduce the likelihood of irritation or allergic reactions. Cons: Cannot be used externally and must be inserted overnight to ensure proper absorption and effectiveness.

NOT FUNDED LOCAL ESTROGEN VAGINAL OPTIONS

VAGIFEM. Individually packaged with applicators. Contains estradiol. Twice weekly application. Box of 18 details at $120.30. Pros: Not messy, making it a convenient option for users. Cons: Expensive.  —————————————————————- ESTRING. $170 for 3 months. Pros: Provides a continuous release of estradiol, which may improve vaginal health and alleviate dryness without the need for daily applications. Cons: Expensive.

Local DHEA Vaginal Option

Dehydroepiandrosterone (DHEA) is a hormone produced by the adrenal glands, with smaller amounts also produced by the ovaries (and testes). Often called a “precursor hormone,” DHEA can be converted into estrogen and testosterone within the body’s tissues.

Vaginal DHEA therapy can help locally increase estrogen levels in vaginal tissues, offering relief from common menopausal symptoms like vaginal dryness, discomfort, and painful intercourse.

DHEA therapy is a vaginal insert that contains prasterone (DHEA). The option available in New Zealand is Intrarosa (vaginal insert) is not not funded.

NOT FUNDED LOCAL VAGINAL DHEA OPTION

INTRAROSA. Intrarosa is a vaginal insert (pessary with applicator) used daily that contains 6.5 mg of a plant-derived form of prasterone (DHEA), combined with coconut and palm oils. As the pessary dissolves, these ingredients help lubricate and nourish the vaginal and surrounding tissues. Available under Section 29. $108 per box of 28. For maintenance some women use 1 every 2nd day or snap them in half. Pros: Provides a non-estrogen option for managing vaginal dryness and discomfort, which may be beneficial for women who cannot use estrogen therapies. Cons: Potential side effects may include vaginal discharge, irritation, or pain. Expensive.

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Understanding the Risks

Slightly higher risk of blood clots, stroke, and breast or endometrial cancer – especially with oral and combined HRT.

Regular reviews and dose adjustments help manage these risks.

The Women’s Health Initiative Study and Context Initial WHI findings (2002) raised safety concerns – often misapplied to younger women. Today: – Modern body‑identical hormones show a safer profile. – HRT started before age 45 – especially in surgical menopause – provides key health benefits. – Expert voices emphasise these risks were overstated for younger users

Side Effects of HRT

Common side effects of hormone replacement therapy (HRT) can vary from mild to more noticeable and may affect each woman differently:

• Change in Bleeding: Periods may return or change, especially if the uterus is intact. Common when starting or adjusting HRT.
• Breast Tenderness: Often caused by estrogen and may settle with time or dosage changes.
• Mood Changes: Some experience irritability or emotional shifts, usually improving as the body adjusts.
• Weight Gain: Often linked to fluid retention or fat distribution – not increased body fat. Also reported without HRT after ovary removal.
• Nausea: Can happen early on or with dose changes; taking HRT with food may help.
• Headaches: Hormone shifts may trigger them; adjusting the dose or type can help.
• Bloating: Estrogen can cause water retention. Staying hydrated and mindful of diet can reduce discomfort.
• Dizziness: Hormonal changes may cause dizziness or vertigo, usually settling over time but can be distressing.
• Abdominal pain: Common in women with endometriosis, as estrogen can trigger symptoms. Progesterone is important to help calm lesions and reduce pain.

While these side effects can be bothersome, they are generally manageable and may lessen as the body acclimates to HRT. It’s important to discuss any persistent or severe side effects with a healthcare provider, who can help tailor the treatment to better suit individual needs.

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References

Australasian Menopause Society, AMS Guide to MHT/HRT Doses New Zealand Only, Dec 2024.

The Menopause Society, formerly known as the North American Menopause Society (NAMS) Position Statement (2022) on Hormone Therapy. 

Delgado BJ, Lopez-Ojeda W. Estrogen, StatPearls. Treasure Island (FL): StatPearls Publishing; Jan 2024 [Updated 26 June 2023].

Cable JK, Grider MH. Physiology, Progesterone. StatPearls. Treasure Island (FL): StatPearls Publishing; Jan 2024 Jan, [Updated 1 May 2023].

British Menopause Society, Testosterone Replacement in Menopause. Dec 2022.

Medical Journal of Australia, Global Consensus Statement on Testosterone Therapy for Women: An Australian Perspective. MJA 2013 (10), 16 Nov 2020, p.449-452. 

British Menopause Society, Management of Unscheduled Bleeding on HRT, [Published: Aug 2024].

NHS, Hormone Implants as Hormone Replacement Therapy (HRT), [Updated: Dec 2024].

Balance, What is Intrarosa and How Do I Use It?, [Created: 23 Aug 2023].

Panay, N., Ang, S. B., Cheshire, R., Goldstein, S. R., Maki, P., & Nappi, R. E. (2024). Menopause and MHT in 2024: addressing the key controversies – an International Menopause Society White Paper. Climacteric, 27(5), 441–457.

Panay, N., Anderson, R. A., Nappi, R. E., Vincent, A. J., Vujovic, S., Webber, L., & Wolfman, W. (2020). Premature ovarian insufficiency: an International Menopause Society White Paper. Climacteric, 23(5), 426–446.

British Menopause Society, Understanding Hormone Levels in the Blood Factsheet, [Published: 29 Sept 2021]. 

[Updated: 9 October 2025]