The Decibel - The debate around using hormone therapy for menopause

Episode Date: March 12, 2024

A new series published by the medical journal, The Lancet says menopause is being “over-medicalized.” It argues that treating aging like an illness does women a disservice. The medical community��s approach to menopause has changed a lot throughout the years including the use of hormone replacement therapy to treat symptoms associated with it.The Globe and Mail’s health reporter Kelly Grant, explains the history of hormone replacement therapy use, the culture shift around our views on menopause and where this all leaves people dealing with its symptoms.Questions? Comments? Ideas? E-mail us at [e-mail]

Hot flashes, night sweats, brain fog. These are just a few of a long list of symptoms associated with menopause. For some, this change of life can be unpleasant. But for others, it can be debilitating. How we treat the symptoms of menopause has changed over the years, particularly when it comes to hormone replacement therapy. Now, a new series from the medical journal The Lancet says that this normal part of aging is becoming, quote, over-medicalized.

The Globe's national health reporter, Kelly Grant, is on the show to talk about this research and how our views on menopause have changed. I'm Maina Karaman-Wilms, and this is The Decibel from The Globe and Mail. Kelly, thank you for being here. Thanks for having me. To get to the moment that we're at today with the conversations around menopause and to talk about this new Lancet series, I think we should maybe just start by laying out a few things. So maybe we'll just go through some basics here, even just definitions, if that's okay. I guess medically, yeah, what is menopause? Sounds like a good place to start. Menopause is your last period. Now, generally, that's something

you can only figure out in retrospect, because as you approach the end of your fertile years, your period tends to get pretty irregular. So once you've gone 12 months without a period, you're considered to be in menopause. Okay. And generally, like on average, when does that happen? 51 is the median age. So we talked about your last period, but medically, I guess, what's happening in your body? Your estrogen levels are starting to go down, namely because your ovaries are getting ready to end the time in which they were involved in making babies. Okay. And so basically, everyone who gets a period will eventually go through menopause? That's right. Most women go through it naturally. There are also women who

experience early menopause because of things like cancer, where their ovaries have to be removed either because they have cancer or because they have a high genetic risk of ovarian cancer. And so some women are kicked into menopause automatically when their ovaries are removed for medical reasons. Okay. And we also talk about perimenopause. What is that?

So that's when you might see, as I mentioned, an irregular period, the beginning of vasomotor symptoms, which is the fancy medical term for things like hot flashes and night sweats. So it's defined really as the years leading up to menopause. All right. You mentioned hot flashes, night sweats. What are some of the other symptoms of menopause and perimenopause? Well, I do want to go back to vasomotor symptoms again, because they are the ones that are most clearly linked to menopause. That's your hot flashes and your night sweats. There's also genitourinary symptoms, so things like vaginal dryness. Then there's a whole host of symptoms that are often associated with menopause, but where the direct link to menopause is less clear in the evidence. So those are things like mood swings, fatigue, muscle soreness. You hear a lot of people talk about brain fog, but it's not as

straightforward as you might think to say those are definitely caused by menopause. You know, one example I like to use is it's very clear that night sweats are associated with menopause. And if you wake up four or five times a night bathed in sweat, it makes sense that you might feel exhausted the next day. Yeah. Okay. Let me ask you now about hormone replacement therapy. So this is something that's been used to treat some of these symptoms. But what is this? It's called HRT sometimes. What is hormone replacement therapy? Well, it's just what it sounds like in the name. It is replacing some of the hormones whose levels drop when you go into menopause. So mainly estrogen. Most women who take HRT take a combination of estrogen and something called progestin,

which is a synthetic version of the hormone progesterone. And the reason why women take that combination is because estrogen alone has been shown to increase the risk of endometrial cancer. So the progesterone helps counter that. If you're a woman who's had a hysterectomy, then you're safe to take estrogen on its own. And is this like a pill, a shot? What's the form? So there are plenty of different options. There's pills, there are creams, there are transdermal patches, there are vaginal applications, so intrauterine devices, that sort of thing. So that's the way you would take your home-born replacement therapy. When did we start using HRT and why, I guess? Why did we start? So HRT goes back to, you know, the early 1900s. It arose for a couple of different reasons. One was a sort of part of the rejuvenation and anti-aging movements of the early 20th century. So, you know, if you think women feel pressure

to remain young now, that pressure has unfortunately always existed. It was originally extracted from farm animals. And then once we got into the 1940s, it was mainly estrogens that were made from pregnant mare's urine. So this is horse's pee? Yes, that is correct. And, you know, it was pretty clear from the beginning that injections of estrogen did make a difference for those vasomotor symptoms that we've been talking about. Okay. And then HRT became kind of really widely prescribed here. I guess, when is a book that came out in the 60s called Feminine Forever by an American gynecologist who was saying like, look, women don't need to decay and age. You know, we have this, a woman's breasts and genital organs will not shrivel. She will be much more pleasant to live with and will not become dull

and unattractive. Wow. Okay. So that was sort of part of the cultural message. And you can hear in that language that that was really not aimed at making life better for women. It was aimed at making life better for the men who were married to these women or spent time with these women. So that's kind of the cultural piece. Then at the same time, there were a host of observational studies that began to make people in the medical community think that hormone therapy could also be useful for preventing the chronic illnesses that become more common as we age. So, namely things like osteoporosis, coronary heart disease, and cognitive impairment. And with the idea that it could both

keep you young, so to speak, and relieve your vasomotor symptoms and perhaps prevent chronic disease that led to fairly wide prescribing in women who were of menopausal age. Okay. But then something kind of changed in the way we view HRT. What happened there? So the big change came in 2002 when the interim results of a big randomized controlled trial called the Women's Health Initiative were released publicly. And to just back up for a quick second, the purpose of that big study, which involved about 27,000 women in the United States between the ages of 50 and 79,

and they were postmenopausal, was not to figure out whether home run replacement therapy worked for vasomotor symptoms. We knew that that was the case. It was to figure out whether home run replacement therapy worked for vasomotor symptoms. We knew that that was the case. It was to figure out whether these hypotheses about chronic disease prevention were actually true. Okay, so this hadn't really been looked at in depth before then if it actually prevented these diseases? There had not been a gold standard big randomized trial, which is in medicine how we determine whether an intervention actually works or not, that hadn't happened on these prevention questions before. And that's what the purpose of the hormone replacement therapy part of the Women's Health Initiative

study was all about. So there was this idea that here we go, this hormone replacement therapy is supposed to prevent some chronic illnesses. And then lo and behold, what they actually find is the opposite. Not only does it seem to not help preventing coronary heart disease, which was the main endpoint of the study, but it raises the risk of several different illnesses. And the one that catches most people's attention and really scares people is an increased risk of invasive breast cancer. So when those results are announced, prescribing of HRT falls off a cliff. And they actually stopped the study, I think, didn't they? They did, yeah. Because it was causing such...

I mean, I shouldn't say they stopped the intervention part. They still continue to follow these women. So the Women's Health Initiative continued and actually continues today. It actually is a study that runs until 2026. But the hormone replacement therapy interventions, they felt they needed to stop it, that the risk was too high. And do we know how much it actually increased the risk of breast cancer, for example? Well, I think it's important when you look at that question to separate the groups by age. And when they went back to take a look at what the increased risk looked like for women between 50 and 59, which is, again, generally the time period when you would most need HRT to relieve those vasomotor symptoms, we're looking at three additional cases of breast cancer for every 1,000 women who use that combined menopausal hormone therapy we talked about earlier.

We're not talking about no risk for that age group, but we are talking about a small risk. And I think for women who were suffering from especially difficult symptoms, they would want to look at this and say, okay, is that risk small enough that I'm willing to take it in exchange for better day-to-day quality of life during menopause? In the years that have passed since that 2002 press conference that really quite scared doctors and women, there have been multiple reanalyses of that Women's Health Initiative data, as well as some other studies of HRT. And what the medical community has come to believe now is that a lot of the increased risk, particularly for breast cancer, was in the older women who participated in the trial. And in truth, I mean, if you're in your 70s, you're probably done having hot flashes,

right? So that's really not the group of women who need these medications. So since that 2002 press conference, the evidence that has emerged has led all of the major medical societies that are involved in prescribing HRT to women to say, we feel that the benefits, particularly for vasomotor symptoms, outweigh the risks if you are in your 50s or less than 10 years out from your last period and you don't have some very clear contraindications. The general advice is that if you're the right age, this is safe for you to take for vasomotor symptoms. We'll be right back. Okay, so since 2002, there's been kind of a re-evaluation, basically, of the medical side of things.

Let's talk about the cultural side of things, too, though, Kelly, because this seems to play a role as well. Yeah, I think it's really interesting that in tandem with this reevaluation of HRT, you've had this cultural rise of the salience of menopause itself. So this is celebrities speaking publicly about their own menopause experiences. Michelle Obama, Gwyneth Paltrow, Drew Barrymore, Naomi Watts, who are speaking publicly about their menopause experience. And then I think you also have a real rise of women who are, you know, in their 50s and 60s, who are leading companies who have big jobs and who don't want menopause to disrupt a time of their life when they're really at the pinnacle of their careers. They're also very often caregivers at home for both aging parents and for younger kids. Women in this age group just have, they've got a lot on their plates,

right? And the idea that you'll just sort of grin and bear it as you go through difficult menopause symptoms. There are a lot of women who are just speaking publicly about the fact that they think that is not okay. Okay, so we've laid out kind of the back and forth and the use of HRT and the rise of kind of other, you know, cultural things. But recently, Kelly, the journal The Lancet actually published a bunch of papers on menopause. What did they publish? This was a series hoping to reframe menopause. It was comprised of four papers, one talking about the over-medicalization of menopause and a hope to empower women to approach menopause in the way that works best for them. And then other papers on early menopause and care and treatment for that, care and treatment of

women who go into menopause because of cancer treatment. And finally, a paper looking at the evidence around menopause and mental health. And we're going to focus on the first one, the over-medicalization of menopause. So tell me about that. What's going on? These international experts writing in The Lancet wanted to make the argument that menopause has been framed in a way that is not particularly helpful to women. They don't like the idea that it's being framed as a disease rather than a natural part of aging that every woman experiences. They pointed as an example to figures from the UK where the use of HRT just

between 2020 and 2022 rose by about 60%. And their argument is really that not every woman who experiences menopause will have these debilitating symptoms and that it does women a disservice to treat menopause as though it were a disease like cancer or heart disease or dementia that always needs to be medicated. And that in fact, it's good to remind women that there are plenty of people who go through menopause without serious and debilitating symptoms and that many women find it quite freeing to be done with their periods, to be done with the risk of an unwanted

or surprised pregnancy. And I have to say, as somebody who's almost 44 and is sort of staring down the barrel of this, it's nice to occasionally be reminded that maybe it won't be a devastating, terrible 10 years of my life. Yeah. So, OK, so it's like kind of reassessing the way we look at things here. Just to be clear, though, the experts who are writing The Lancet, are they are they against the use of HRT? They're not. What they wanted to make clear was that for women who have severe vasomotor symptoms, that HRT works well for helping with those symptoms and women should absolutely have access to those medications and treatments. They just don't want it to be portrayed as though every woman goes through debilitating menopause symptoms. They also didn't

like the idea that if you sometimes look on the internet, you can see, you know, like a hundred different symptoms that are associated with menopause. And so they also wanted to be clear about what symptoms are actually linked by the evidence to menopause, just to be a little bit more grounded in science when we talk about this phase of life. And we talked about the stats out of the UK with the use of HRT. Do we have any stats in Canada or North America to compare? Not in Canada, unfortunately.

We don't have any good national numbers on the prescribing of HRT in Canada, which unfortunately is very common with Canadian healthcare data. However, we do know anecdotally and from at least one published study that involved Canadians in an international survey that Canada does not seem to be one of the countries that has very extremely high prescribing rates for HRT. I don't think this has much to do with Canadian women's attitude towards HRT or desire for HRT. I think in speaking to menopause specialists in the country, it has more to do with our lack of access. We have a lot of people who don't have a family doctor. And then we have a lot of family doctors who are reluctant to prescribe HRT. There was a whole generation of doctors who weren't taught much about this in medical school, in part because in the wake of the Women's Health Initiative results, there just wasn't much prescribing of this going on.

The general message was at that time, this is too risky. So when you combine that with the fact that the menopause specialists we do have often have quite long waiting lists, we may have an access problem when it comes to HRT in Canada. Okay. And we've been talking about HRT treatments, but I guess I wonder, are there other treatments to deal with symptoms of menopause? Like if there's maybe, you know, if there were concerns for so long around HRT, were other treatments developed? So cognitive behavioral therapy has some good evidence behind it as being helpful for vasomotor symptoms. There are a few other drugs other than hormone replacement therapies, things like gabapentin and a couple of SSRIs that have some evidence for helping with some of the symptoms of menopause, although none of them seem to work as well as HRT does. There is also a new class of drugs called neurokinin-3 receptor agonists that aren't hormonal replacement. Instead, what they do is help stabilize the temperature control center in the brain,

which is what sort of goes out of whack when estrogen levels fall off at menopause. There is one drug called Fezolinatant that has been approved by the US FDA that falls into this class, but it's not yet been approved in Canada. So yeah, there are some options here, but I guess I just wonder, why aren't there more? Like, especially in that period where we weren't actually prescribing HRT because of the potential danger to people's health, why weren't there more options available? HRT has good evidence for helping with vasomotor symptoms, which is, for most menopausal women, the most bothersome symptom. In that period where the fear was that the risk of HRT

outweighed the benefits, I think a lot of what happened during that time was that women were just expected to sort of grit their teeth and bear it, right? And rather than having a more nuanced conversation about how serious are your hot flashes and night sweats? Are they really disrupting your life? Are they making it so that you're so exhausted during the day that you come into work and you're not performing as well as you could or being as good of a mother, daughter, caregiver, friend as you would like to be? And how was that weighed against the risks that were initially identified in that 2002 press conference about about the Women's Health Initiative? Yeah. And we've touched on this a little bit then. And this this that your last answer kind of gets to it, too, because, you know, for a long time, menopause was kind of seen as a stage of life that maybe didn't get talked about a lot or didn't get addressed.

And now it seems like we're talking about it more and more. How is our understanding of this stage of life, I guess, changed over the years? I think it has changed because women have changed. And by that, I mean that 40, 50, 60 years ago, I don't think there was an expectation that women in their 50s would be at the pinnacle of their working lives and careers. So the role of women in society has changed. Now, I don't think that all of the stigma around menopause has gone away. And that's because I don't think all of the pressure to stay young has in any way changed. I think that still plagues women. And I wish we could find a way to get rid of it, but I don't think we're there yet. Yeah. So I guess, like, where

does this leave us just, you know, in terms of how we should approach or think about this stage of life? How should we approach this? I am somewhat encouraged by the fact that we have reconsidered the role of HRT and that those medications are considered less risky than they once were. I mean, I think in Canada, we still have access problems. But to me, the big picture is like, we want to do whatever we can to help women fulfill their potential at this time of life. And if HRT allows women to do that, I think it's great. At the same time, I, again, as like a premenopausal woman, do love hearing from folks like the experts who wrote in The Lancet that this isn't terrible for everyone, that there are women who go through menopause with minimal symptoms and then find

themselves quite joyful at being freed from those worries around their periods and pregnancies. Kelly, thank you so much for taking the time to be here. Thanks for having me. That's it for today. I'm Maina Karaman-Wilms. Our intern is Manjot Singh. Our producers are Madeline White, Cheryl Sutherland, and Rachel Levy-McLaughlin. David Crosby edits the show. Adrienne Chung is our senior producer. And Angela Pachenza is our executive editor. Thanks so much for listening, and I'll talk to you tomorrow.