Myths & facts about menopause & HRT
Women have been misled about menopause, however it's never too late to advocate for your health 💪
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Happy summer! And welcome to my new subscribers. There are now more than 29,000 of you, and it’s humbling to see this community grow and learn from one another. I can’t thank you enough for your support.
Menopause and perimenopause have been called a woman’s “personal summer.” In honor of this phenomenon, I’m posting the two-part interview I did with
about hormonal health.Shannon is a speaker, author, and Founder Emerita of Moms Demand Action. She has been named a Time Magazine 100 Most Influential People and a Glamour Woman of the Year for building the largest women’s volunteer organization in America. I’m grateful for her support as she elevates women’s voices around the country.
Menopause is having a moment in the popular media. For far too long, women’s health has taken a back seat. The time is now (and twenty-plus years overdue) to set the record straight on HRT and to dispense fact-based, nuanced information to help women make informed decisions about their hormonal health.
Separating myth from fact has never been harder in our current landscape of social media, the wellness industry, and the “guru-ification” of the medical space. And while I try to remain humble about what I don’t know, I do know this: hormone replacement therapy (HRT) has been woefully under-prescribed for over 20 years—ever since the Women’s Health Initiative came out in 2002. Women are entitled to the truth about the risks and benefits of hormone therapy, especially given that the benefits of HRT outweigh the risks for the vast majority of women if it is initiated within the first ten years of a woman’s menopause.
Of course there are risks of taking HRT. There also are risks of not taking HRT, too. I hope you enjoy the following Q&As where Shannon and I tackle these thorny issues.
Shannon Watts: Before we get into menopause, tell us a bit about perimenopause - signs of it, what to expect, and when women should see their doctors to talk more about it.
Lucy McBride: Perimenopause is defined as the stretch of time—usually seven to ten years—leading up to menopause. The symptoms of perimenopause vary widely. The most common symptom of perimenopause is irregular periods (i.e., periods that are longer or shorter in duration and/or periods with a longer or shorter interval between them.) Other common symptoms include a low libido, vaginal dryness, hot flashes, joint pains, urinary tract infections, pain with sex, fatigue, moodiness, irritability, heart palpitations, and dry skin—among others.
Note that some women don’t experience any of these symptoms; others will be debilitated by them. This is due to the variable production of hormones by a woman’s ovaries as they gradually slow down.
My advice is that all women, particularly in their 40s, report symptoms of menstrual irregularities and other hormonal symptoms to their doctor. Of course we don’t want to over-treat a normal biological process; it’s also important for women to understand the various hormonal, behavioral and lifestyle treatment options for bothersome perimenopausal symptoms.
SW: How do women know when they actually are in menopause, and what should women ask their doctors about this next phase of their lives?
LM: Menopause is defined as having done a full year without a menstrual period. In the case of non-menstruating women (e.g., women who have had a hysterectomy), menopause is defined as having symptoms and/or laboratory testing to suggest that the ovaries are no longer producing robust amounts of estrogen and progesterone. As per the previous question, women who are in perimenopause and menopause may experience a range of symptoms, and to varying degrees.
My best advice for women at this phase is to ask their doctor about hormone replacement therapy (HRT). Specifically, I suggest asking how HRT might help 1) ameliorate any current menopausal symptoms and 2) prevent the long-term effects of the absence of estrogen and progesterone in the body. Imagine yourself when you’re 80, I tell my middle-aged patients. Ask about the specific risks and benefits of HRT for your body, using the latest medical evidence about HRT to guide the conversation. Know that biased, anecdotal and fear-based messaging about HRT is everywhere! It can be difficult to cut through the noise, so be sure to find someone who has access to the facts and the humility to know what they don’t know.
SW: There are so many misconceptions about hormone replacement therapy (HRT) due to flawed or outdated science. Tell us a bit more about HRT- why is it important, what misconceptions are being told, and what do women most need to know?
LM: When a woman experiences symptoms that interfere with her quality of life and when the benefits of hormone therapy outweigh the risks, the most effective way to treat symptoms caused by declining or absent hormones is by taking hormone therapy. Just like any medical intervention, however, HRT carries risk.
So, the question of how to treat your particular symptoms hinges on the potential risks and the likely benefits of hormone therapy for you (and only you). Because some of the symptoms are subjective (i.e. quantifying stiff joints, hot flashes, or irritability is more difficult than, say, measuring cholesterol), a decision about hormones should include quality of life issues in addition to measurable data.
It’s also important to remember that there are long-term benefits of hormone replacement therapy, beyond simply treating immediate symptoms. HRT has important long-term benefits on bone, brain, and heart health—to name a few.
In other words, there are risks of taking hormones; there also are risks of not taking hormones. (Click here for the most recent expert guidelines that nicely capture the risk-benefit ratio of hormone replacement therapy. And be sure to talk with your doctor.)
Too many women needlessly suffer through menopause because of false narratives about the safety of HRT and because discussions about quality of life often aren’t prioritized.
SW: What should women do if her doctor tells her she shouldn’t take or isn’t a candidate for HRT?
LM: The first thing I suggest is to make sure that your doctor’s advice stems from a careful appraisal of current medical evidence. Even in my own medical training, I was taught not to prescribe HRT unless a woman was absolutely miserable—and, if prescribed, it should be only in the smallest doses and for the least amount of time.
It’s important to note that for women who are appropriately advised not to take HRT or for those who decide not to, there are some non-hormonal remedies for menopausal symptoms. Examples:
For stiff joints: The combination of strength training and stretching is critical. Our joints have to work harder when the surrounding muscles are weak or tight. For example, our knees absorb more wear-and-tear if our quadricep (thigh) muscles are weak and/or stiff. Particularly as we age, women should aim to include muscle tone and elasticity in their exercise routines.
For hot flashes: Behavioral changes such as limiting alcohol, caffeine, and spicy foods; wearing light clothing; and turning on fans can help reduce hot flashes and night sweats. So can managing your stress and other activities, such as public speaking, that tend to spike adrenaline levels. You can also consider natural supplements (e.g., black cohosh, evening primrose, and vitamin E) or prescription medications (e.g., Gabapentin or an SSRI medication like Effexor) which can provide some relief. The upshot? These treatment recommendations are nuanced and depend on the patient. It’s always best to talk with your primary care provider about your specific needs and tolerance for symptoms versus side effects from different therapies.
For insomnia: I wrote a longer post on SLEEP here.
SW: Can women who aren’t candidates for systemic HRT use vaginal estrogen?
LM: Yes! Vaginal estrogen has been shown to improve symptoms of genitourinary syndrome of menopause (GSM) which includes vaginal dryness and the increased risk of urinary infections as a result of thin, atrophic vaginal tissue. Vaginal estrogen is typically safe for women, even those with a family or personal history of breast cancer. Vaginal estrogen can significantly improve the quality of life for women who are prone to UTIs. The North American Menopause Society’s expert guidelines on HRT are here. My friend and sexual medicine expert Dr. Rachel Rubin’s advice about vaginal estrogen is here.
SW: Why do you think the medical establishment has ignored the health of middle-aged women for so long?
LM: I think there are a number of reasons women have been deprived of access to data and nuanced guidance:
Women historically have been left out of medical research studies. Without adequate data, the medical establishment has been unable to adequately address women’s health risks and needs.
Medical education has historically overlooked women’s health. Even at Harvard Med School in the late 90s, I received little education about menopause—something that 100% of my women patients will experience! I’ve learned everything I know about menopause from critically appraising the literature and from learning from colleagues like Sharon Malone MD and Rachel Rubin MD, and from my own patients.
The U.S. healthcare system is broken. Even the most well-trained, well-intended GYNs and primary care doctors aren’t given enough time with patients to hear their concerns and discuss complex issues like menopause, sexual health, and long-term risk reduction. In my opinion, it’s a failure of our medical system that women haven’t been adequately heard—and that we haven’t prioritized QUALITY of life issues like patients deserve.
Women are accustomed to suffering. We are socialized to be caregivers more than “care-receivers.” As a result, we haven’t spoken up about things like insomnia, low libido, painful sex, or pelvic floor problems. We accepted the risks of osteoporosis, heart disease, and cognitive decline because we thought we had to. We thought they were normal or no big deal. Whereas men’s health has taken priority, women have silently suffered for too long.
Which is why it was thrilling when Bernadine Healy was appointed the first female director of the NIH. She launched the Women’s Health Initiative (WHI), the largest-ever randomized controlled trial studying only women—and the effects of specific prevention strategies on major causes of death and disability in post-menopausal women.
Among other things, the WHI compared the risk of breast cancer among women who took estrogen and synthetic progesterone to women who did not take hormones. In 2002, the study was halted early because of a possible signal between hormone therapy and breast cancer. The media ran wild. It created a lot of fear and false narratives about HRT that to this day have been difficult to undo.
News headlines screamed, “Researchers conclude that hormone replacement increases the risk for breast cancer!” However, what wasn’t reported was that in absolute numbers, the risk amounted to less than one additional breast cancer case per thousand women per year. The study also didn’t prove causation. In fact, women in this study who took estrogen alone (i.e., not in combination with synthetic progesterone) actually had a decreased risk for breast cancer.
This, too, was left out of much of the reporting.
Of course breast cancer is a top cause of morbidity and mortality. Medicine’s job includes helping prevent and screen for breast cancer. But depriving women of the facts about hormone therapy is not okay—especially when the data are clear that the benefits for most women under the age of 60 outweigh the risks.
It has taken decades to correct the fear-based narratives about a treatment that can be life-altering for so many women.
Disclaimer: The views expressed here are entirely my own. They do not reflect those of my employer, nor are they a substitute for advice from your personal physician.
Could not agree more. I felt so much better taking HRT into my 70's. I'm 81 and still taking a low dose estrodial + progesterone. There's no history of breast cancer in my family so my variety of doctors over the years have been willing to continue to prescribe it.
I recently started on HRT after my osteoporosis diagnosis. I'm 57 and used Depoprovera for birth control before menopause. I immediately saw increase in energy level. I'm retired and very active. Thankful for the medical team that supported my request to consider HRT. I did have to change OBGYN to find a doctor who understood the benefit for my symptoms. Thanks for sharing this information on HRT.