Between the charlatanism and the fearmongering, menopausal hormone therapy can make a miraculous difference.
The internet has a way of presenting fads and trends that our patients bring to us.
A couple of years ago, it was the weight-loss peptides.
Now, it seems, hormone-replacement therapy (HRT), recently renamed menopausal hormone therapy (MHT), is having a moment and the internet is losing its mind.
As usual there are the opportunists, including many medical doctors, spruiking unfounded therapies such as bioidentical MHT and the use of testosterone in perimenopausal women. They’re also the ones telling women that perimenopause may be starting from 35 or so.
In my practice, I’ve met women who come in armed with reels and videos from these medical influencers, asking if this is something they need to consider.
Do they need a panel of hormones? (Hormone panels do not tell us if you’re in perimenopause or menopause unless you have amenorrhoea due to IUD, PCOS etc.)
Do they need a DUTCH test? (There is no evidence this test shows anything.)
Do they need oestrogen on their face to bank their collagen?
Should they be on MHT and not the COCP which is working fine for them?
And I have other women who come in with symptoms suggestive of perimenopause, of the right age group (40s), who are struggling, and who believe they should not consider MHT. Who are scared of breast cancer despite no family history.
To the former group, I often say, “the clinical definition of menopause is …” and “there is as yet no consensus that non-TGA-registered tests and medications work” and “if you need contraception and have no reason not to be on it, the COCP may be a better choice until 50-52″.
To the latter group, it’s a long, hard conversation about their symptoms, excluding other causes of their symptoms and then seeing if they may be open to trialling MHT: “What’s the worst? You try it for three months, and if don’t like it, or it does nothing, you stop it. You can now exclude it as an option.”
My mother had an abdominal hysterectomy, for reasons that are unclear to me in hindsight, in her early 40s. It appears she had a TAHBSO, for some reason, and it plunged her into menopause that led to her suffering for over two decades. She was not given the option of the COCP or anything else.
This was in the late 1990s, not long before the Women’s Health Initiative study that would ruin it all for women for 20 years and counting.
I was an O&G registrar studying for my written exams and the WHI trial was one we had to study in preparation for that year. I learnt firsthand the errors in interpretation and the errors in choosing the cohort to study that led to the widespread panic that caused doctors to tell women to get off their HRT.
If reports are to be believed, some 40% of women were routinely placed on MHT prior to the WHI trial. Today, that number is around 4% and the fear of using MHT, as with vaccines causing autism, is hard to debunk despite the widespread suffering of women.
It became deeply personal for me this year, as I finally gave in to a trial of MHT for myself in perimenopause as a last resort.
I’d had deep, whole-body aches since my early 40s, while raising four kids entirely solo, switching specialities last minute, working fulltime and studying and passing the three-part RACGP exams. I was depressed and, as I’ve written before, for at least 18-24 months of that period, chronically suicidal.
I had no time to focus on the small aches and pains, but these were so much more. I remember, at one point, talking to my lovely male GP of the time, asking him why I had these aches that woke me up at night, with accompanying night sweats. He looked at me in confusion, and said “let’s exclude a malignancy” and ordered some tests, which all came back normal.
Life carried on. As did my symptoms, which I simply learnt to accept.
It’s only in the past year or two, with new information that we have on menopause, perimenopause and the impacts on the musculoskeletal system, whole-body aches, sleep disruption, genitourinary changes and more, that I thought, “hang on a minute…”
Now when I screen my patients, I ask for so much more than just hot flushes and loss of libido.
Does she experience whole-body aches? Frozen joints? Is she waking up at night to go to the toilet when this was not the case before? Is she suffering from urge incontinence for the first time?
I am surprised at the answers I get. Sometimes the patients have not themselves recognised the changes, until asked about, and then they are grateful to learn that it may be amenable to treatment.
As to whether they ought to be on the COCP or MHT, while many on the internet are trash-talking the COCP, I have had the occasional woman come in unexpectedly pregnant in her late 40s because she believed she was perimenopausal and no longer needed contraception.
These are all conversations we need to be having with our patients.
Having been on MHT myself some months now, it’s been life-changing.
My global aches have improved, and I can feel the impact when, recently, I ran out of my MHT and got too busy to get a refill. Within some weeks, I was back to creaking around feeling 80 and I realised I was getting nocturia three to four times a night. Within two weeks of recommencing MHT, my symptoms resolved.
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Many of my perimenopausal ladies suffer from low libido. Adding MHT makes a big difference to mood, energy levels and libido that isn’t what they refer to as “pity sex” – i.e. performed out of pity for their spouse.
A smaller number, those who are postmenopausal with hypoactive sexual desire disorder, have trialled topical testosterone after three to six months of MHT first, and are blown away by the improvement in their energy and libido. One patient sent me a message thanking me: “After having suffered for five years, I’m so grateful.”
We are on the path to listening to women more, in every facet of life, including in health. We are recognising that the medical field has done women a gross disservice, in research and in other ways, by treating us as “smaller versions of men”. There is no better time to rectify that.
When we reach perimenopause in our 40s and 50s and then menopause, we have on average another three or four decades of life ahead of us, free of childrearing. It’s only right that, having sacrificed decades to our families, we now focus on the things that make us happy and feel our best so we age well and remain fit and nimble.
It is well beyond time, and we owe it to the women in our lives, as our patients, as spouses and partners, to do this well to help them and ourselves.
Dr Imaan Joshi is a Sydney GP; she tweets @imaanjoshi.
