Approximately 6,000 women in our nation enter menopause each day, usually during their 50s. For some, it’s no big deal; for others, though, “the change” can be debilitating. Menopause can be more than just inconvenient hot flashes and mood swings (although those are common symptoms). It can also cause intense bouts of anxiety, depression, changes in skin conditions, difficulty sleeping, discomfort during sex, weight gain, chronic fatigue, thinning hair, vaginal dryness and feelings of a loss of self. For some women, menopause is a disruptive force that impacts their relationships and careers. 

Over the years these symptoms have been regulated through hormone replacement therapy (HRT), sometimes called menopausal hormone therapy. In the 1990s, some 15 million women a year received HRT. But in 2002 a single study with questionable design found links between hormone therapy and elevated risks of breast cancer and heart disease. Thanks to some well-intentioned but misleading media attention, panic ensued and prescriptions for the treatment plummeted. Although recent studies have shown that the benefits of taking hormones can outweigh the risks, the impacts of this nationwide panic are still felt today, and women are paying the price.

The Problematic Study

The Women’s Health Initiative (WHI) was created in 1991 to study different health outcomes for 160,000 postmenopausal women over the course of 15 years. A study on HRT was just one aspect of their research that was expected to last about eight years but was halted prematurely in June 2002. On July 9, the WHI held a press conference to announce why the study had been aborted, which essentially boiled down to “the adverse effects outweigh and outnumber the benefits.” The adverse effects they referred to were a small but statistically significant increased risk — “less than a tenth of 1 percent per year” — of cardiac events and breast cancer. 

Over the next several weeks, as news about the study quickly spread, statistics were presented in ways that were (unintentionally) misleading. In her article titled, “Women Have Been Misled About Menopause” in The New York Times (which is a must-read, honestly), Susan Dominus discusses a “Today” show segment in which Ann Curry said, “…to be specific here, you actually found that heart disease, the risk increased by 29 percent. The risks of strokes increased by 41 percent. It doubled the risk of blood clots. Invasive breast cancer risk increased by 26 percent.” While this was accurate, it was misinterpreted by the vast majority of people listening. As Dominus explains, the statistics could also be presented this way: “A woman’s risk of having breast cancer between the ages of 50 and 60 is around 2.33%. Increasing that risk by 26% would mean elevating it to 2.94%. (Smoking, by contrast, increases cancer risk by 2,600%.)” In other words, for every 10,000 women who take hormones, an additional eight will develop breast cancer.

In addition to the misinterpretation of results, the study was flawed in its design. 

The WHI wanted to be able to measure health outcomes (such as who ended up having strokes, etc.) and since many of these wouldn’t appear until women were in their 70s or 80s, they weighted the participants toward women who were already 60 or older. That meant that women in their 50s, who tended to be healthier and usually had more menopausal symptoms, were underrepresented. At the time, it wasn’t deemed important to differentiate risk by age, but we now know that age is a major factor when it comes to HRT.

Newer Studies

Since the disastrous response to the WHI study, evidence has amassed that the benefits of HRT may outweigh the risks for healthy women under the age of 60 who are experiencing troublesome symptoms. For some, these positive gains go beyond relieving hot flashes and night sweats; studies have since been published showing that some women suffer fewer bone fractures, a 20% lower incidence of diabetes, and in certain cases, a lower rate of breast cancer

One study from 2022 suggests that HRT timing is critical:

“Totality of evidence indicates menopausal hormone replacement therapy (HRT) effects are determined by timing of initiation according to age and/or time-since-menopause, underlying health of target tissue and duration of therapy. Initiated in women <60 years of age and/or at or near menopause, HRT significantly reduces all-cause mortality and cardiovascular disease (CVD) whereas other primary CVD prevention therapies fail to do so.”

This is big news for several reasons. Firstly, it establishes that HRT will not increase a woman’s risk of cardiovascular disease when initiated early enough. Secondly — and perhaps even more importantly — it shows that HRT can actually help prevent CVD. In the introduction to the study, the authors note that CVD is the number one killer of women, causing 1 in 3.2 deaths each year in this country. Women experience heart disease differently than men, which can lead to problems recognizing and diagnosing the issue, and they also face an increased risk of heart disease after they go through menopause. This same study surmises that this is because estrogen exhibits a “cardioprotective effect,” and the loss of the hormone experienced postmenopause leads to the age-associated increase in CVD incidence.

Bar graph comparing age to incidence of cardiovascular disease in premenopausual and postmenopausual women
“Incidence of cardiovascular disease in women is both age-associated and age-specific as reported from the Framingham Study. In addition to an increase in cardiovascular disease incidence by age in women, postmenopausal women have a two- to six-fold greater incidence of cardiovascular disease than premenopausal women across the age range <40–54 years.” (Source: “Menopausal HRT and Reduction of All-Cause Mortality and Cardiovascular Disease: It’s About Time and Timing”/U.S. National Library of Medicine.)

Doctors Need to Catch Up

A scientific review published last year offered proposals for better HRT guidance for medical professionals. Essentially, the purpose of the review was to spread awareness about the “confusion” our country can’t seem to shake regarding HRT: 

“Four major North American medical societies, the American College of Obstetricians and Gynecologists, American Association of Clinical Endocrinology, the Endocrine Society, and the North American Menopause Society, now recommend HRT in appropriate patients for the management of menopausal symptoms. Despite these evidence-based recommendations, physicians, including cardiologists, are reluctant to use HRT because of confusion and lack of education regarding which patients are appropriate for HRT use.”

JoAnn Manson, chief of the division of preventive medicine at Brigham and Women’s Hospital (and one of the chief investigators of the WHI study) has tried to spread the word that HRT has been unfairly defamed, but she’s getting frustrated with the lack of response among medical professionals, too. “Women who would be appropriate candidates are being denied hormone therapy for the treatment of their symptoms,” she said in Dominus’ Times article.

A damning 2017 survey of residency programs in family medicine, internal medicine and OB/GYN revealed that only 6.8% of residents felt they were being adequately prepared to manage menopausal patients effectively. Of 177 respondents, 20% reported not receiving any menopause lectures during residency. The conclusion of the survey found that residency trainees recognized the importance of understanding menopause management, but were being inadequately trained by their educational institutions. This has led to an entire generation of doctors who suffer from a potentially significant blind spot.

What Should Women Do?

Women who are suffering from perimenopausal symptoms often feel stuck between a rock and a hard place. Their doctor might not be educated in managing their symptoms — so no help there — so who can they turn to for help? The internet? If you aren’t an expert in digital literacy, researching medical information online is a potentially dangerous solution; the internet is absolutely rife with misinformation, particularly when it comes to women’s health.

One route may be to seek a medical practitioner who specializes in functional or holistic medicine. These doctors tend to think outside the lines compared to your typical primary care manager, so you might have a better chance of finding someone who has educated themselves on the matter.

Alternatively, you can seek help from a third-party menopause care provider. There’s been a boom of companies that provide menopause therapies through various online services, such as Midi or Alloy

Top image by Elen11 from Getty Images, via Canva.com


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