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It’s been 200 years since a French physician coined the term “menopause.” And for most of that time, it was spoken of in euphemisms (“she’s going through ‘the change’”). However, the conversation is finally shifting—now, you can’t open Instagram without hearing about it. Menopause itself is simply the day that marks 12 months since your last period, which usually happens between the ages of 45 and 55. But perimenopause starts up to 10 years earlier, during which fluctuating estrogen levels can cause a smorgasbord of unpleasant symptoms, from hot flushes and brain fog to aching joints and vaginal dryness. There are new treatments, too—like hormone replacement therapy.
What is hormone replacement therapy?
Despite a newfound willingness to talk about all these symptoms, there’s still confusion over the most common treatment: hormone replacement therapy (HRT). Currently, standard HRT is a combination of estrogen and progesterone. It may be administered as a pill, gel, patch, or spray, and you can start taking it when you’re perimenopausal before your periods actually stop.
“HRT is recommended for intrusive menopause symptoms,” says Professor Annice Mukherjee, consultant endocrinologist and author of The Complete Guide to Menopause. “Used in midlife, it also helps keep your bones strong. But with longer-term use, especially in women with complex health issues and those older than 60, the risks, for some, start to outweigh the benefits.”
Is hormone replacement therapy good for you?
It s complicated. Some studies have found there s a higher chance of uterine or breast cancer, which sounds bad on paper, but the risk is low in healthy women under 60. Most doctors are now pro-HRT for anyone struggling with symptoms, although some remain more cautious than others.
Frustratingly, as with many aspects of women’s health, there’s scant medical research, and many doctors have not had menopause training, so your GP might not be as informed as you’d hope unless they have personally sought additional education.
Dr. Juliet Balfour is a GP with an Advanced Certificate in Menopause Care from the Royal College of Obstetricians and Gynaecologists (like Professor Mukherjee, she is also a member of the British Menopause Society’s Medical Advisory Council). “There’s a need for more good-quality research on women’s health issues,” she says. “Randomized double-blind placebo-controlled trials take years and are expensive. We have good evidence for many of the benefits of HRT, but some clinicians discuss benefits that are not yet backed up by evidence.”
Dr. Louise Newson, the founder of the Newson Health Menopause and Wellbeing Center, has been at the forefront of changing the conversation around menopause, but has also been subject to criticism for prescribing higher doses of estrogen than NHS guidelines. “HRT is safe, but there’s a wealth of misinformation around it, often scaring women away, and I want to change that narrative,” she says. “I want women to feel empowered to advocate for themselves when speaking with their doctors. Too often, women are dismissed or told that their symptoms are just something they have to put up with… That’s simply not the case.”
Dr. Newson says the benefits go beyond relieving day-to-day symptoms: “HRT can be effective in reducing the risk of diseases including osteoporosis, heart disease, and dementia.” She also mentions another hormone: testosterone, which, can be prescribed for anxiety, brain fog, and libido. She directs me to her own pilot study on this, which found that a woman s mood, cognition, and libido all improved using it.
Dr. Balfour says the current evidence on dementia is conflicting, but there is a benefit for women who are in early menopause and under the age of 45. More research is needed on testosterone before recommendations are made, although she adds: “If the results do show these benefits, we will need to make testosterone much more accessible to women on the NHS.”
All the experts agree that HRT is not right for everyone. It’s unlikely to be prescribed if you’ve had, or are at risk of, breast cancer. Around 80% of breast tumors are estrogen-driven, and some cancer treatments, such as Tamoxifen, actually work by blocking estrogen, so—clearly—adding more estrogen into that situation would be unwise. Having said that, there are exceptions. If your breast cancer is not estrogen-driven, and you are under 45, some doctors will prescribe HRT on the basis that the benefits (for heart, brain, and bones) outweigh the risks.
One of doctors’ key concerns is that women might feel that HRT has them covered in terms of everyday symptoms and long-term health, and so become complacent about nutrition, exercise, sleep, and stress management. “HRT is not a miracle cure,” says Professor Mukherjee. “Many non-specific symptoms have other causes. Medication is not automatically needed for natural menopause. In fact, women have more agency than the monetized menopause industry would have us think.”
She points me to a report published in The Lancet last year. It received criticism for using the phrase “over-medicalized,” which some took to mean that women should cope without interventions like HRT. “But it’s not anti-HRT,” she says, “just anti-misinformation.” The paper recommends more exercise, less alcohol, and the use of cognitive behavioural therapy for anxiety and poor sleep. This is, of course, excellent advice for anyone.
Every doctor I spoke with is in agreement when it comes to the importance of optimizing nutrition, exercise, and lifestyle. The largest study on menopause and nutrition to date, which was conducted by Zoe, found that menopause impacts blood sugar control and microbiome composition, leading to increased inflammation, body fat and greater risk of cardiovascular disease. This can be mitigated by eating well and exercising. So if you survived your twenties and thirties on wine, convenience foods, a sedentary lifestyle, and little sleep, you’ll probably find that won’t work in your forties and fifties.
Menowashing
Meanwhile, many women have turned to the flourishing menopause market to assuage symptoms, and brands have leaped on this opportunity. There are menopause-branded beauty products, supplements, cooling packs, and, ridiculously, chocolate. The practice of slapping the word “menopause” on a product and then doubling the price has been termed “menowashing”.
However, not all of these products are bad. “Science-backed supplements can play a role in the management of menopause symptoms,” says Dr Shahzadi Harper, author of The Perimenopause Solution. “The estrobolome is a set of gut bacteria responsible for regulating hormones, which can reduce bloating, weight gain, and mood changes. So a probiotic supplement with clinically proven ingredients, like Better Gut from The Better Menopause, can be beneficial.”
While we work on improving our lifestyles and experiment with supplements, HRT remains a powerful tool in many women’s menopause arsenal. “It’s a drum that I’ve been banging for almost a decade, since the NICE guidelines were rewritten to include HRT back in 2015,” says Mariella Frostrup, chair of Menopause Mandate and the government’s newly-announced menopause employment ambassador. “Then, I was a lone voice singing its praises. Now we’re sitting on a veritable iceberg of robust data as to its benefits and minimal risks.”
She says the key is education, so that women can recognize that symptoms, such as anxiety or insomnia, might be down to menopause. They can then make informed decisions about possible treatment. Despite advances in both science and attitudes, we still have a long way to go. “We’re fighting millennia of medical gaslighting,” sighs Frostrup. “But, for the majority of women, HRT has more benefits than risks.”