Menopause is not a disease.

By Margaret McCartney and Deborah Cohen, MARCH 7, 2024

The menopause is having a moment. Once only spoken of rarely, and with embarrassment, it is now sensationalised in the media. This has been accompanied by a massive increase in prescriptions for Hormone Replacement Therapy, which have more than doubled in England in the past 5 years. But is this hormone revolution really helping women?

It is true that misogyny prevails in the medical profession and that women’s healthcare is often overlooked and under-researched: just look at the current attitude towards endometriosis and the crisis in childbirth and after-care. But there is a greater philosophical question here that needs to be interrogated: Is menopause a disease of oestrogen and ageing that should be treated? Or are we instead pathologising and medicalising a normal part of the female life cycle?

This week, The Lancet medical journal published a series of articles examining the current media narrative, saying it’s “time for a balanced conversation about menopause”. Its editorial states that, while some women experience severe symptoms, others have mild or no symptoms. And despite the frequent claims that menopause is associated with poor mental health, it states that “there is no strong evidence that the risk of first-onset clinical depression is increased over the menopause” — although some women with previous mental illness may be at risk.

Menopause wasn’t always taken so seriously. There was a time when women were expected to shut up and put up with their hot flushes. We darkly referred to this stage of life as “the Change”. But then, the bestselling book Feminine Forever, by gynaecologist Dr Robert Wilson, changed that narrative forever. He made the case that menopause was a serious disease and that post-menopausal women were deficient: “a woman’s physical, social, and psychological fulfilment all depend on one critical test: her ability to attract a suitable mate and to hold his interest for many years.” He described menopause as “a mutilation of the whole body” and HRT was a way to “be restored along with a fully feminine appearance”.

Though some feminists fought back, many health activists embraced the view that, like contraception, HRT was a key to women’s liberation. But what wasn’t common knowledge at the time was that Wilson was funded by the HRT industry.

There followed an inevitable surge in demand for HRT until, in the early 2000s, a large study from the Women’s Health Initiative reported an increased risk of breast cancer associated with long-term HRT use. Overnight, the treatment fell out of fashion. That study has now been contested, and in the past decade, the medication has had a renaissance. Parliamentarians are calling for menopause health checks, and leave from work, and social media is full of doctors recommending it to women — and women recommending it to each other — not just as a way to reduce hot flushes, but as a way to save marriages, skin tone, and sex lives — as well as reducing future cardiac and dementia risks.

But do all these claims stack up? The National Institute for Health and Care Excellence is the official provider of evidence-based guidelines for UK doctors. In 2015, they published their “first guideline on menopause to stop women suffering in silence”. One of the guideline developers said: “For the past decade, some GPs have been worried about prescribing HRT, and women worried about taking it. I hope that this new NICE guideline will empower women to talk to their GP or practice nurse about menopause and provide them with information on the range of options that could help. For health professionals, the guideline should boost their confidence in prescribing HRT.”

In other words, women should be asking for HRT, and GPs should be prescribing more of it. And certainly, there is good-quality evidence that HRT is highly effective at reducing the hot flushes and sweats that many women experience. But it also comes with side effects — in particular, the risk of certain cancers and, where oestrogen is taken as tablets, an increased risk of blood clots.

Annice Mukherjee, a consultant endocrinologist with a specialist interest in the menopause, says: “Women who want to access HRT should be able to get it on the NHS. But I think it’s just gone from one extreme to another… What we need is balance. Some women will benefit from some treatments but not others. Some women will come to harm from some treatments and not others. Treatments like HRT are being oversold for that potential benefit.”

One area of controversy is whether HRT has preventative properties. NICE says that HRT can be used to treat vasomotor symptoms — flushes, sweats and “low mood that arises as a result of the menopause”. It is also listed as effective for the treatment of osteoporosis, though other drugs are preferred. The Medicines and Healthcare products Regulatory Agency (MHRA) advises that HRT should only be prescribed to relieve post-menopausal symptoms that are adversely affecting quality of life — for example, poor sleep caused by night sweats, in turn causing fatigue or low mood — and say that “treatment should be reviewed regularly to ensure the minimum effective dose is used for the shortest duration”.

It’s important, though, not to confuse correlation with causation. Treating flushes with HRT to improve sleep is often helpful. But given the exterior factors often affecting women at this stage in their lives — looking after younger or older family members, as well as the impact of the gender pay gap —  the menopause might not be the sole trigger for their mood swings. And if HRT fails to remedy these problems, patients can end up on escalating doses rather than being encouraged to explore whether another factor might be the problem.

Indeed, anxiety, weight gain, fatigue, and low mood are rising across society because of poor physical mobility in midlife. But because of the health propaganda campaign, women attribute it to the menopause, says Mukherjee. “This may be contributing, but they go on HRT and this doesn’t help.”

“It’ll treat flushes, but they weren’t a problem anyway,” she continues. “And then they’ll say that they have heavy bleeding or weight gain or bloating, or migraines are getting worse. Some doctors will then just escalate the doses up, and up, and up. And then, if it’s not working, they are put on testosterone.” She adds: “The evidence for testosterone for those general symptoms is zero. Again, that’s all propaganda.”

Growing awareness is exacerbating the problem, piling pressure on doctors to prescribe. As a result of powerful activism, access to HRT is sometimes seen as a “rights” issue for women.

Brooke Nickel is a public health researcher at the University of Sydney, whose work has looked at the language used to sell HRT products to women. “They’re really spinning that feminist narrative around,” she says. “If you don’t do something, you’re not taking control of your body or you’re being oppressed by other people.”

“They then either conceal or downplay the evidence,” she continues. “They don’t talk about harms, they only talk about benefits, they only spin it in a positive way. So it’s not really giving transparency or giving all the information to women.”

Mukherjee agrees. “People are using HRT as a panacea and it’s not a panacea. They think it’s going to prevent heart disease, dementia, diabetes, etc. Some doctors say, if it doesn’t make its symptoms better, it doesn’t matter. It’s going to prevent disease.” The trouble is, we simply don’t know which of those women is going to develop complications. “We know from previous research there might be one in 50 women who get a breast cancer diagnosis with five years of treatments,” Mukherjee says.

Social media is complicating the landscape even further. Dr Liz O’Riordan, a former breast surgeon who has been treated for breast cancer herself, says: “Lots of members of the public are getting their information from celebrity influencers.” Some make an effort to be accurate, she says, but not all. There are also some high-profile doctors claiming menopause is a disease that must be treated, and that if you don’t take HRT you will get heart disease and dementia.

This is confusing for women in the breast cancer community, as many can’t take HRT due to the risk of their cancer worsening or returning. Nor does O’Riordan think that the risks of HRT — which include breast cancer and for some preparations blood clots — are fairly explained online. Notably, however, NICE’s draft guidance explicitly does not recommend that HRT is used to prevent cardiovascular disease or dementia.

Normally, if a treatment is not working, we reconsider whether the diagnosis is correct. But in this case, it’s different. “It’s a bit like Tripadvisor — we are not getting a balanced view,” says O’Riordan. “A lot of women don’t need HRT, instead we only hear the worst stories about menopause and as a result women are scared, asking, ‘if we don’t take it what’s going to happen to us?’ There is a real fear for the future.”

Consider what happened after NICE’s updated draft guidance for managing menopause was published recently. There was an outcry on social media about one particular recommendation: cognitive behavioural therapy, which NICE said can “reduce the frequency and severity of hot flushes and night sweats and should be considered alongside or as an alternative to HRT”. One post in response read: “Talking therapy for menopause is insulting, cruel and pointless.”

Myra Hunter would disagree. The emeritus professor has been researching menopause for most of her professional life, and argues that CBT can make a real difference to women who are experiencing hot flushes and sweats. She’s not against HRT, but thinks that menopause can best be understood through a “biopsychosocial” framework that considers biology, psychology and social factors.

“Our minds and bodies are intrinsically linked,” she says. “CBT has been used to help people to manage physical symptoms, such as chronic pain, for some time… We should not say that CBT is a cure-all — it’s not. It’s a choice for women. It may not get rid of symptoms entirely, but it might reduce the negative impact they have on her life.”

In fact, the NICE draft guidance says that CBT should only be “considered” for help with flushes — and still primarily recommends HRT. No-one is saying that menopausal symptoms are all psychological. Hunter also observes that the meaning and experience of menopause varies across cultures. “In some countries, such as Japan or India, women tend to report fewer [hot flushes]; and there may be other factors which explain these differences, such as diet and nutrition.”

Hunter has also noticed a resurgence of the Sixties idea that HRT can make you look younger, sexier, and less wrinkled. “I’ve been struck by women asking about testosterone, even when they are doing well, thinking it may help give them ‘energy’ or make them feel more ‘lively’.” HRT marketing has created a demand that wouldn’t otherwise exist.

Perhaps we should be grateful for this blossoming interest in women’s health. But this wave of concern comes with strings attached. It’s not helping women to insist that we all “need” HRT, or to promote it to treat conditions where there simply isn’t evidence for it working. We need independent information — not to be oversold products like consumers in a marketplace. By treating post-menopausal women as “deficient” in hormones, rather than going through a normal stage in life, women are being medicalised. And is that really doing them a favour?

(Sources: UnHerd)