“The Truth About Hormone Therapy”

Author: Stephanie Osfield

If you’re wary, confused or mistrustful about taking hormone therapy to relieve menopause symptoms, then you really need to read this. Find out why experts can’t recommend the treatment enough.

It’s 6pm and, after powering through a brisk walk and evening shower, Penny Johnson is slathering a special clear gel on her skin. But this is no anti-ageing serum infused with mineral peptides, probiotics or green tea. It contains 1.25mg of oestrogen per dose, measured out in one ‘pump’, to relieve her menopausal symptoms. Every day, Penny, a 56-year-old Sydney primary school teacher, rubs the gel along her upper arm, alternating with the other arm the next night. “After only two months, my energy levels and sleep have really improved and my skin, eyes and vagina are no longer super dry,” she explains. “My anxiety is far less and I’m not getting recurring bladder infections, so that’s been a huge relief.”

In trying hormone treatment for menopausal blahs, Penny is in a small minority. Most women give MHT (menopausal hormone therapy, formerly hormone replacement therapy, or HRT) a big miss in any form. According to Australian research, only 13 per cent of Aussie women in their 50s take MHT. Yet many do a daily dance with menopausal symptoms ranging from hot flushes, night sweats, vaginal dryness and weight gain to dry, itchy skin, low libido, brain fog, anxiety and mood swings. “Though 20 per cent of women have no symptoms around menopause, 80 per cent experience symptoms and 20 per cent have symptoms that go on for more than five years,” says Dr Sonia Davison, president of the Australasian Menopause Society.

RIDING THE HORMONE ROLLER- COASTER

Rusty on your menopause basics? Here’s a quick refresher. As you hit your 40s, hormone levels can start to fluctuate, kick-starting perimenopause, which is sometimes signposted by menstrual changes. Oestrogen levels may start to rise and fall like a big dipper, triggering hot flushes, which may ramp up closer to your very last period, which heralds menopause, often around age 51.

Enter MHT, which can be a woman’s best friend. First sold in the 1930s in injectable form, by the ’60s, MHT pills sat alongside lipsticks and compacts on the bathroom shelves of many menopausal women. Over the decades, new and improved options appeared. Cut to the present and MHT is available in many different options, including gels, capsules, nasal sprays, an IUD, vaginal pessaries/creams and patches of oestrogen alone or combined oestrogen/progestogen (the synthetic form of progesterone). “As well as being the most effective treatment for menopausal symptoms, MHT can be beneficial for a woman’s bone health and cardiovascular function,” says Dr Davison.

“Some studies have shown different forms of MHT can reduce the risk of developing type 2 diabetes and colorectal cancer.” That’s an impressive roll call of benefits, so why are women with menopausal issues still soldiering on without MHT?

MISGUIDED SAFETY FEARS

MHT took a big blow to its reputation in 2002, when the US Women’s Health Initiative Study (WHI) found a higher breast cancer risk in women taking both oestrogen and progestogen pills for more than five years. As headlines screamed ‘MHT causes breast cancer’, women all over the world panicked and binned their pills, patches and pessaries. But the results were blown out of proportion.

According to Dr Jen Gunter, in her book, The Menopause Manifesto, in real terms the study actually found that “six additional women developed breast cancer a year for every 10,000 who took MHT, which is slightly less than 0.1 per cent of women on MHT a year.” Since then, studies have shown that taking MHT earlier may boost longevity. “Women using MHT between the ages of 50 and 59 have a 30 per cent lower risk of dying versus women given a placebo,” Dr Gunter points out.

Regardless, the hype still holds sway. “From 2002, the number of women taking MHT dramatically dropped, as women needlessly abandoned a treatment that offered them enormous and important relief from menopause symptoms,” says Dr Davison. What women weren’t told? That the 2002 WHI study was designed to check if MHT protects against heart disease, so it included mostly women in their 60s and 70s and half were smokers or ex-smokers. “This meant that this group of women already had a higher risk of breast cancer, due to their age and other lifestyle factors,” Dr Davison explains. The study also used only one type of oestrogen and one type of progestogen, both in tablet form. “Based on just one form of MHT, the research findings can’t be applied to other more current types and delivery methods, such as patches or patches combined with pills,” Dr Davison says. Ditto for research involving Oxford University, which was published in medical journal The Lancet in 2019. Though it too found a higher risk of breast cancer in women taking combined MHT, the 58 studies it reviewed were, in fact, based on old data and types of MHT, which had higher hormone levels that are no longer recommended or often prescribed.

“Now when a woman uses combined MHT, we often prescribe an oestrogen patch and a newer form of micronised progestogen, which is closer to natural progesterone,” says Professor Jayashri Kulkarni, a leading women’s health and hormone expert and director of Monash Alfred Psychiatry Research Centre in Melbourne. This safer combo doesn’t increase breast cancer risk within five years of use, the Lancet study found. And for women taking oestrogen-only MHT for seven years, it actually lowered their risk of breast cancer, the 2002 WHI study discovered. Yet these good news stories have barely been reported.

“The sensationalising around MHT and breast cancer risk is a huge injustice in women’s health that has condemned several generations of women to a far poorer quality of life through their menopausal years,” says Professor Kulkarni. “The very small risk of breast cancer linked to MHT is far less than the risk if a woman gains substantial weight or drinks daily. Yet women who drink wine each night with dinner are too afraid to take MHT, even when their symptoms are compromising their ability to work or causing relationship issues due to exhaustion, irritability or low sex drive.”

Doctors can feed this fear at the front line, where, with the best of intentions, they talk women out of MHT. “Unfortunately, many GPs have little training in menopause and many aren’t well informed about the limitations of the MHT research,” says Professor Kulkarni. “So, I advise women to look for a medical doctor who specialises in women’s hormone health and can trial different combinations of MHT to find the best fit.” To help women out, the Australasian Menopause Society offers a ‘Find a Doctor’ page on their website and a symptom score sheet to print and fill in to take to their GP visit to help the doctor target the best treatment. First though, many women prefer to take a ‘natural’ approach, trying herbs like red clover and black cohosh. Some find that’s all they need to take the edge off their menopausal blips.

Others see complementary therapists and take bioidentical hormones. “They mistakenly think that bioidenticals are safer because they’re based on plant ingredients like yam,” Professor Kulkarni says. “But not only have these ingredients been synthesised in a lab, they also have no long-term studies showing they’re safe or effective.”

At her GP’s urging, Sally Greenfield, 49, tried herbal remedies for her severe hot flushes, which often had her in tears. “I saw a naturopath and spent thousands of dollars on a whole lot of supplements, but, eight months later, I was still red- faced, miserable and dripping with perspiration every day,” says the allied health trainer from Victoria. After three more visits to her GP, who kept dissuading her from MHT, Sally saw another doctor for a referral to a hormone specialist. “The endocrinologist was horrified that I’d been made to suffer so long and immediately prescribed MHT,” she says. “Within weeks, the hot flushes had dropped to just a few a day. I was overjoyed and felt I had my old self and life back.”

ENJOYING LIFE AGAIN

Menopause can make it harder for some women to find their happy place and Zen zone. “Harvard research has shown that depression is 16-fold higher in menopausal women,” says Professor Kulkarni.

“I constantly see women with severe depression or anxiety triggered by menopause and they’ve been prescribed antidepressants that aren’t working because their hormones are the main cause. When they start taking MHT, their lives are transformed. Within weeks, they go from crying every day and experiencing constant butterflies, anxiety attacks and low mood, to feeling more calm, able to laugh, get out of bed with energy and enjoy life again.”

That’s exactly what happened to Melbourne nurse Maryke Vaartjes, 56. She says she white-knuckled it through four years of perimenopause in her 40s, suffering depression, migraines and night sweats so bad she had to get up and shower or change her sheets. “The antidepressants I was prescribed barely helped, but finally I saw a women’s hormone specialist who prescribed an MHT called Tibolone, which completely turned my life around,” Maryke recalls. Within a week, her mood had lifted. Within a month, the night sweats were almost gone and she no longer suffered migraines or nocturia – getting up four times a night to pee. “Six years later, when I went through menopause, I had to change to a different MHT, so I thought I’d take a break to see if I still needed it. But, within weeks, my symptoms came back. It was a big wake-up call, reminding me just how much MHT has improved my quality of life.”

How long can she stay on MHT? The answer is not one size fits all and, for each woman, depends on family history and personal preferences. Some try it for a year or draw the line at the five-year mark. Other women decide that maxing their quality of life and bone and heart health right now is top priority. So, they take MHT and schedule into their diary the recommended regular physical exams, ultrasounds and mammograms to monitor their breast health. “There’s no set treatment duration, but the use of MHT shouldbe reviewed annually and, unless a woman has premature menopause, the lowest dose that can control symptoms should be used,” advises Dr Davison. “A woman’s family history and any other health conditions should also be taken into consideration.”

For Maryke, the benefits of MHT far outweigh the risks. “MHT gave me back my sleep and cured my depression,” she says. “It stopped my brain fog and increased my energy, so that I was able to get back to regular swing dance classes and group bike rides with my girlfriends.” Obviously, there’s no ‘right’ way to do menopause and every woman has to navigate her own path, but it’s important to remember that MHT has perks for heart and bone health and may also increase longevity. So, if menopause is feeling like a long hormonal haul, don’t rule MHT out. It could help you travel your menopausal years in greater comfort and even give your health a boost en route.

Looking for support? Visit the Australasian Menopause Society and check out the following pages: Find a doctor to find health professionals from every state. Telehealth consultations are also available. The symptom score sheet is a downloadable symptom score sheet that can serve as a valuable diagnostic tool.

Alternatively listen to our podcast Thriving in Menopause to learn more about menopause from our experts.