The Personalised Approach for MHT Selection According to Women’s Androgen Status During Menopausal Transition

Beyond the Hot Flash: The New Frontier of Androgen Balance

For decades, the conversation around menopausal hormone therapy (MHT) has focused almost exclusively on replacing estrogen and progesterone to stop hot flashes and night sweats. But the medical landscape is shifting. Experts are now recognizing that menopause isn’t just about the loss of estrogen; it’s about a complex systemic decline in hormones, including androgens.

Androgens are often mistakenly viewed as “male” hormones, but they are fundamental for women. They play a critical role in maintaining cognitive function, sexual health, metabolic stability, and overall systemic well-being. As we look toward the future of women’s health, the trend is moving away from simple symptom suppression and toward a more holistic preservation of the body’s hormonal equilibrium.

Why SHBG is the New Metric to Watch

One of the most significant trends in hormonal management is the increased focus on Sex Hormone-Binding Globulin (SHBG). Perceive of SHBG as a “carrier” protein that binds to testosterone; when SHBG levels change, the amount of “free” or active testosterone available to your tissues also changes.

Recent data highlights how different delivery methods of MHT can impact these levels. In a prospective, multicentre study of 148 perimenopausal women, researchers found that fixed-dose oral MHT (containing oestradiol and dydrogesterone) led to a statistically significant increase in SHBG levels. Specifically, levels rose to 48.3 nmol/L at six months and reached 50.32 nmol/L by the 12-month mark.

In contrast, women using transdermal oestradiol combined with oral dydrogesterone, or those using non-hormonal management, showed no significant changes in SHBG. This suggests that the method of hormone delivery—oral versus transdermal—can fundamentally change how the body handles androgens.

For clinicians and patients, measuring SHBG is becoming a practical tool to predict how a woman will respond to therapy and to evaluate her overall androgen status before choosing a treatment path. [Internal Link: Understanding Your Hormone Panel]

Dydrogesterone: A Game-Changer for Testosterone Preservation

Not all progestogens are created equal. A major concern with some MHT regimens is their tendency to induce a decline in testosterone levels, which can lead to fatigue, brain fog, and a loss of libido.

The future of MHT likely lies in “androgen-preserving” options. Dydrogesterone, a highly selective progestogen, is emerging as a rational therapeutic choice. Evidence indicates that when used as part of oral MHT, dydrogesterone does not have a suppressive effect on baseline androgen concentrations.

In the study mentioned above, total testosterone levels remained stable throughout the 12-month observation period for those using the oestradiol/dydrogesterone combination. This preservation of endogenous androgens is vital for women who want to maintain their muscle mass, bone density, and cognitive sharpness during the menopausal transition.

The Shift Toward Personalized Hormonal Mapping

We are entering an era of “precision menopause.” Rather than a one-size-fits-all prescription, the trend is moving toward personalized hormonal mapping. This involves analyzing a woman’s specific baseline—including her SHBG and total testosterone—to decide between oral and transdermal routes.

For some women, increasing SHBG via oral therapy may be desirable. For others, maintaining a steady state via transdermal patches or gels may be the better route. The goal is no longer just “stopping the symptoms,” but optimizing the metabolic and cognitive environment of the body.

As research continues, we can expect to see more integrated protocols that treat the “climacteric” period as a systemic transition requiring a balanced cocktail of hormones, rather than just a deficiency of estrogen. [External Link: World Health Organization – Women’s Health]

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