Some US doctors don’t understand menopause
A new analysis of a controversial study affirms something menopause experts have long argued: For many women, the benefits of short-term hormone replacement therapy (HRT) outweigh their risks.
The news drops at a time when menopause is having a moment. Celebrities are talking openly about their journeys, while businesses, the medical establishment and the government are waking up to the needs of the 75 million women in the US experiencing perimenopause, menopause or are postmenopausal.
But it’s a moment that must be backed by solid data, not guesswork. A recent AARP survey estimates that menopause costs the US about US$1.8 billion in worker productivity losses and $24 billion in related health care.
To be clear, hormones are not a panacea, nor are they the right choice for every woman. But the messaging around the use of estrogen and progestin has been so muddled for so long that the treatment has become emblematic of the overall state of health care for women who have passed their reproductive years.
Women entering midlife simply aren’t being given straightforward, accurate information from their doctors — too often, they’re told nothing at all, or worse, given the wrong message.
All of the confusion began back in 2002, when the world of women’s health was rocked by the abrupt cessation of a large study called the Women’s Health Initiative. Designed to understand whether hormones could lower a woman’s risk of certain diseases, the researchers instead found treatment was raising the risk of heart disease, strokes and breast cancer. The message was that women taking hormones should stop them and others shouldn’t start.
That altered the course of care, depriving a generation of women from therapy that is known to treat common menopause symptoms, like hot flashes, night sweats, dryness and bone loss.
The new data, shared last week in the Journal of the American Medical Association, came from following this women enrolled in the study for 20 years. Researchers found that decades on, hormone therapy could offer meaningful benefits while posing few risks for women in the early stages of menopause. It is also safe to use for most women in their 60s and 70s who are experiencing more severe symptoms, like hot flashes and night sweats.
Importantly, HRT did not increase the risk of heart attacks. Nor did short-term use of both estrogen and progestin raise the risk of breast cancer. Moreover, since the Women’s Health Initiative was halted, a raft of newer products have emerged to offer different delivery methods — often at much lower doses — that might further minimise their health risks, though the authors noted more study is needed.
For menopause experts, this update feels like old news. But having it stated in plain language in a medical journal is still a big deal.
Not all doctors have kept up with the times. Lisa Larkin, president of The Menopause Society, says she regularly hears from women whose physicians refuse to prescribe HRT, with one just last week telling her that her doctor claimed to adhere to a “hormone-free practice”.
The lingering divisiveness was underscored by a series of editorials published in March in The Lancet arguing that menopause is a natural process that has become over-medicalised. The editors focus their critique on HRT, suggesting companies are appropriating “feminist narratives” to push hormone therapy without acknowledging the risks.
We should be wary of movements that want to turn a normal life process into a disease or sell us something to fix a problem they’ve invented. But the authors go on to perpetuate myths about the universal dangers of HRT — now firmly debunked. And just because symptoms are “natural” doesn’t mean they aren’t uncomfortable or disruptive — or undeserving of treatment.
Rather than being over-treated, most women “are left to navigate their perimenopausal and menopausal years with no medical guidance whatsoever”, as a group of Stanford University menopause specialists noted in their response to The Lancet.
Doctors in the US aren’t sufficiently educated to offer women good advice. One survey of US medical trainees found that only 7% said they felt sufficiently trained to help women during menopause. Another survey of OB-GYN trainees found that less than a third were exposed to a menopause curriculum during their residency. Yes, you read that right: Even some gynaecologists aren’t offered guidance on ushering women through perimenopause and menopause.
That’s left women to fill in the blanks themselves. They might find solace in the upswell of specialists taking to social media to put out accurate information about menopause. Or they could consult a cluster of new books (from The Menopause Manifesto to The New Menopause) that empower women with solid information and the right questions to ask.
Still, I worry about how much work we are putting on patients. Menopause is a transition that affects half the population; women shouldn’t have to rely on social media, which can have as many charlatans as true experts, nor should they have to sift through the medical studies themselves.
A few burgeoning efforts could help. President Joe Biden’s recent executive order creating a fund to close the knowledge gap around women’s health includes money for improving our understanding of and care for menopause. And Congress should pass a bill introduced last week by a bipartisan group of senators intended to support training, research and awareness around menopause with $275 million over five years.
It’s a start. For a transition that half the population will experience, it should not be so hard to have a thoughtful conversation with a knowledgeable physician.