Do we over-medicalise menopause?

On 5th March, The Lancet publicised an article entitled “Time for a balanced conversation about menopause”. In this article, the authors argue that menopause is a natural phase of life that women transition as a part of biological aging. The gist of the rest of the article is that Menopausal Hormonal Therapy (MHT otherwise known as HRT) is being overused and the risks of MHT are being downplayed by “feminist organisations”.

Let’s look at some facts and figures:

Perimenopause and menopausal symptoms are caused by a loss of ovarian hormones (mainly oestradiol/oestrogen) as the ovaries cease working when a woman’s ovaries are running out of eggs.

All women will experience perimenopause and menopause if they live long enough, and three quarters of those women will experience symptoms that will impact their life. 1 in 4 suffer from severe debilitating symptoms. Menopausal women typically have a huge amount expected of them (work, house children, aging parents etc) and yet only around 15% of Australian women are prescribed MHT. That is a lot of women who are NOT being treated.

Oestradiol is a protective hormone and oestrogen receptors are present all over the female body. Our body systems work better with oestrogen and oestradiol has a buffering effect against other hormones. Oestrogen deficiency can cause menopausal women to become insulin resistant and more vulnerable to the effects of the stress hormone cortisol. Both cortisol and insulin resistance can contribute to weight gain, and, in addition, oestrogen deficiency can cause our joints and muscles to get stiff and painful and it can be difficult to exercise. Excessive weight gain can be a major cause of morbidity and mortality.

Menopause is not just about hot flushes. When our brains do not have oestrogen, we can suffer mood changes, depression, anxiety and brain fog. Without oestrogen, we can get dryness of the skin, eyes, and vagina, this can impact the pelvic floor, recurrent UTIs and painful sex.

Body-identical transdermal MHT is very safe. Transdermal MHT does not have the risk of thrombosis associated with taking oral oestrogens. Breast cancer remains a contentious issue as the 2002 clinical trials studied women on synthetic oral not body-identical MHT but even then only showed a 4:1000 increased risk of breast cancer diagnosis. It did not show an increased risk of death from breast cancer in women taking MHT. The highest increased risk of developing breast cancer is due to being overweight or obese. The WHI data, when properly reanalysed, showed a massive 30% risk reduction in death from all causes in women taking MHT.

As recently as the Victorian era, the life expectancy of a woman was around the age of 57Y, so the “natural aging” argument just doesn’t make sense when women are now typically living for 30-40 Years after menopause instead of just a few years. The oestrogen deficiency experienced at menopause accelerates the risks of age-related disease. 1 in 3 women will have osteoporosis/osteopenia after menopause and the rates of heart disease rise by 5-fold immediately after menopause. Heart disease remains the biggest killer of Australian Women.

There are some good suggestions in the Lancet article about other ways of managing some perimenopausal and menopausal symptoms but we do know that nothing works as well as MHT and women are much more likely to be medicalised in other ways by being prescribed other medications such as antidepressants for their depression/anxiety/mood changes, antibiotics for their recurrent UTIs, pain relief for their joint and muscles pains etc if they are not prescribed MHT. We need to remain healthy for longer.

Author.

Dr Karen Osborne BSc. (Hons) MBBS MRCGP DRCOG DFSRH FRACGP With a dedicated focus on reproductive and sexual health.