33 things I think about HRT right now
aka a moderate midlife and menopause journalist's take on a polarized topic
I was walking this week and thinking about how I feel about HRT, and how I feel about how everyone is talking about HRT, and it was like a pot bubbling up and over.
And then I had to get it out.
Soon – once I stopped walking obviously – I had written this list you are about to read.
And of course it’s massive.
The truth is, I’ve been scared to say what I think. Because it’s hard to even know what to think, and I think about this every day. Obviously I don’t want to make mistakes on this, and when you write things down, you risk being wrong. And because people get so triggered on topics like this. I don’t want to hurt, upset or scare anyone.
So please. This is what I think. That’s it. It’s not about you. It’s about me.
There are two reasons it is not more filled with citations and links:
I wrote this list as if I was talking to you over a cup of coffee, not as though I am journalist filing a report. It’s a bit more laissez-faire. It’s all based on interviews, research, and experiences, so if you want anything backed up, give me a shout.
I’m at a stage in my own perimenopausal journey – and struggling with some sucky but dealwithable health challenges that I’ll talk about when I’m a little stronger – where I am doing the most and the least at the same damn time. I am tired, but not quitting. I am less-to-middling. I am in my last half-menomester. This is what I could do.
Anyway, when it comes to HRT, I clearly feel and think all the things!
Here they are, just for you:
I think the science is robust and the recommendations from guiding bodies are too for using HRT to help with some of the top menopause symptoms.
HRT is not a magic bullet and it’s not risk-free.
I think HRT is probably best treated as an accessory (as British endocrinologist Dr Annice Mukherjee describes it), or a light dusting (as retired US ob-gyn Dr Christiane Northrup describes it), on top of lifestyle changes. That’s because it doesn’t work the same way for everyone, and it can’t fix everything.
If I was on hormone therapy, I would make sure to have regular testing and monitoring by a doctor who listens to me and accepts my feedback and adjusts accordingly.
The research is really behind on HRT; when I checked on Pubmed, there have only been 92k studies on menopause versus a million or so on pregnancy. Many of the studies don’t make distinctions in the kinds of HRT used. Who knows what the research will turn up, if it ever gets ramped up.
There is all kinds of confusion in the medical community about menopause, HRT, and what the research actually says; you wouldn’t believe the variations between practitioners. There is a menopause care gap because of this; it’s like a medical hot potato, and it involves us. There is also a tremendous commercial opportunity. I feel this is a dangerous combination.
I would not be getting my primary information on the benefits and risks of HRT from people who are in the business of selling it. Many of those social media accounts and websites provide awesome information and are run by great people doing great things; I see others that are very obviously compromised and biased and some of them are just plain misleading and irresponsible. I listen to that information with as many gains of salt as I need, take it on board, and weigh it against that given from people who don’t have such obvious commercial interests. (By the way I love commercial interests! I have some of my own!)
I’m not a doctor, but I see no reason why “low and slow”, the guidance for cannabis therapy, is not applicable to HRT. Low doses to start unless there is a compelling medical reason makes a lot of common sense to me; I want somewhere to go.
If I was going on hormone therapy I would have a full workup first, including thyroid, checking for fatty liver, gut health, etc, to make sure I wasn’t adding hormones on top of an underlying condition that might be masked and continuing to cause damage in the background.
I think it can’t hurt to find out how you are metabolizing estrogen, among other things, before starting HRT. I’m very interested in this and want to research more. Multiple forward-thinking experts have said this. It’s something I think a lot of doctors don’t think about, but I feel like it makes common sense. There are good ways and bad ways that this is done in our body, why not, if you can, find out? I think while the science isn’t robust for the Dutch test now, it might be in the future and it can’t hurt. But I also think that this test is expensive and out-of-reach for a lot of people, and a good practitioner can probably figure out or get a good idea of what’s going on with how you present.
I love breathless enthusiasm, but not when it comes to people promoting and persuading me to put something into my body. I will always be careful about this, and do what I feel in my heart and gut is right for me.
The science is robust that estrogen helps prevent bone loss, but so does exercise and diet and not smoking etc. So I’m not sure I would go on HRT just to protect my bones, but get me some Dexa scan results and see what tune I’m singing.
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The science is less clear and mixed on other prevention fronts when it comes to HRT, including dementia; we really need to do a risk/benefit assessment with our doctor. I get continually confused on this, because people I respect (and others I really don’t) seem so certain.
At this point, I personally would not go on HRT just for prevention of cardiovascular disease. This latest review and an upcoming podcast interview with the lead author that I just wrapped back that up, for now. Will new research challenge this? Possibly. Can you find studies now to make a compelling case for prevention? Yes, and that’s why I’m sticking to reviews and what the majority of guiding bodies say internationally. I think if you need/want to go on HRT, the evidence is pretty clear that a window of opportunity, ie closest to your day of menopause, is best for starting. Luckily the evidence is robust for the heart benefits on lifestyle interventions like exercise, diet, social connections, not smoking, challenging yourself, having a sense of purpose, combatting stress, etc.
HRT quite possibly could have a role in health, longevity and vitality, because the most forward-thinking people in this space (integrative, functional, naturopathic) believe it does and they are always 10 or 20 years ahead of the research. I really look forward to this unfolding.
A lot of women can’t take HRT because they’ve had cancer or some other contraindication, it doesn’t work for them, they don’t need it (don’t hate them) and a lot of women don’t want to take it. I might be one of them; I’m really not sure and as I said I’ve got some health problems that my intuition – and my doctor – is telling me to sort out first. I don’t like all the pressure out there; I don’t like having to renew prescriptions, and in a zombie apocalypse or some other kind of worst-case scenario, I don’t want to have to worry about estrogen withdrawal in addition to fighting for food. I’m also bad at taking things every day, particularly if I must apply them to myself. I’m lazy. Those are my current issues.
Estrogen withdrawal, aka second menopause, is a thing you don’t hear about very often. I’ll get to it.
The idea of having to use vag-E (vaginal estrogen) for the rest of my life is unappealing to me, and at this point I don’t need really need it, but I know I might. I think if it came to it, I might also get some vag-T (that’s vaginal testosterone), because I’ve done a couple of interviews with American nurse practitioner Brooke Faught about it. She presented to The North American Menopause Society and she knows her stuff, and she makes a lot of sense. But I’d really rather search for a longer-lasting solution; they are out there and I’m going to be doing some reporting on that in upcoming issues.
Many people in the world never take hormone therapy, are thriving and live to an old age. Many women who have come before us have done this too. Anyone who says we just started going through menopause 100 years ago because we just started living past 50 and that’s why we need HRT doesn’t have much common sense or the scantest knowledge of recent history.
There are a lot of things HRT can’t fix at this time, and a lot of things that happen during the peri/menopause transition that are impossible to unpack it from: ill parents, job losses, divorce, unprocessed trauma, socioeconomic factors, etc etc. Let alone the fact that we all just went through a global pandemic and all that meant. It was stressful for everyone.
Hunter-gatherer tribes like the Hazda in Africa don’t even have a word for menopause and barely experience anything; they have no HRT but they walk all day and they take care of one another and get sun and nature and eat whole foods and don’t smoke or vape or take pharmaceuticals or use screens and wifi or plastic or perfumes and scents – you get my point.
The HRT conversation, since HRT began, has always focused weirdly on estrogen, to the exclusion of progesterone, testosterone et al. Why?
I think perimenopause HRT care needs to be differentiated, and given its own guidelines for treatment, and become its own area of expertise.
Progesterone is weirdly overlooked, it appears to work well for sleep, mood and hot flashes, has good evidence and makes common sense, particularly in perimenopause. Endocrinologist Dr Jerilynn Prior is a leading expert on this, and naturopathic doctor Lara Briden too. Your progesterone plummets in perimenopause, but your estrogen rises and falls, and there are times when you have far too much of it and not enough of that good P-rone. (I’m going to try to make that nickname stick). That’s progesterone, the bioidentical, close-to-what-your-body-makes version, not medroxyprogesterone/progestin, the synthetic version.
I’m bothered by how many doctors don’t show concern about progestin (that’s synthetic progesterone). It seems to have all the side effects and risks, and none of the benefits.
We start losing testosterone when we are in our 20s, not all of a sudden in perimenopause. It’s probably worth looking at for low libido, according to the evidence, and possibly for other things, based on the clinical experience of doctors who prescribe it. Some people are even using it to enlarge their clitorises, if you are into that kind of thing. I’d want to be careful with it, and a lot of experts want you to be careful with it too. But if you want to T-rone it up, go for it. It’s your body.
I’m really interested in DHEA, which helps produce other hormones, including testosterone, progesterone and estrogen, and also falls during this time. Studies have been mixed, and minimal. If I ran the world I’d do clinical trials with an eye to developing a DHEA patch (with hormones, the ability for patents lies in the delivery system). If I tried HRT and had issues, I would find a practitioner who could guide me through DHEA. When I crashed and all my eyelashes fell out in my early 40s, DHEA under the supervision of a naturopathic doctor was part of the regime that turned things around for me.
Bioidentical hormones are most similar to the hormones our body makes, and should probably be called biosimilar. They are not a scam; and they seem safer. They are made by pharmaceutical companies AND by compounding pharmacies. There is a lot of bullshit mumbo jumbo said by doctors on social media on this topic.
Of all the things to be concerned about, I’m not concerned about compounding pharmacies, especially after my most popular podcast episode on them.
If you are concerned, there are a load of bioidentical hormone preparations (patches, gels, sprays, pills) made by pharmaceutical companies who have patented the delivery system, and that means that they are regulated, monitored standardized and approved.
If I was on hormone therapy I would not be drinking much alcohol at all. I lean on a large Danish study and common sense for this.
There is clearly a cultural and commercial push to portray HRT as an essential antidote to being a woman who is aging (and thus heading for disease), and it's rooted in the patriarchy even as it’s being pushed by women on women. I don’t really understand this, but it involves scare tactics that don’t hold up to scrutiny or common sense. If there’s anything I’ve learned by now, it’s that the loudest people usually know the least. I think it’s okay to take HRT and not buy into this. I think it’s okay not to take it. It’s just good to be aware of it.
Taking HRT is not giving up or giving in. It’s using the tools of modern life at our disposal to make life easier.
There it is. That’s everything I can think of. I’m sure I’ll change some of these views, and soon. And I’ll let you know when I do.
As always, you do you.
One thing I know for sure: this is the time to figure out what that means.
PS Comment if you spot a typo, disagree with something, have anything to add.
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Anne Marie. This is awesome. Thank you again for sharing your stories and experiences in such an honest and laissaz-faire way. I love that you’re not afraid to take on controversial topics, because you’re right, and there are a lot of polarized views and negative players in this menopause game. Well done!
I found myself nodding to a lot of what you listed here. I’ve come to a lot of the same conclusions based on my understanding up to this point. I do not have any underlying health conditions and have about 15 years of healthy nutrition/lifestyle under my belt which has been instrumental in my perimenopause journey. It is a shame we don’t spend more effort helping women with how to implement the proven lifestyle strategies you mentioned. Women should be fully educated and equipped with that information so we can do our best during our years leading up to menopause. I am working on some services to help provide that kind of info/support to women seeking a smoother transition - from nutrition to lifestyle to environment since those things help all kinds of other aspects of health as well. It will be interesting to watch how it all unfolds and where it goes.