Are You There, God? It’s Me, Menopause

Take, for example, menopausal hormone therapy (MHT), which is estrogen (and the addition of a progestogen for women with a uterus to prevent the estrogen from causing endometrial cancer). This is one of the most needlessly controversial treatments in women’s health. The Women’s Health Initiative (WHI), a large study on MHT, was halted prematurely in 2002 in part due to data that indicated a 26% increased risk of breast cancer. The headlines were dramatic and scary, and the use of MHT plummeted.

In practical, what-does-this-mean-for-me terms, the 26% risk from MHT translated into slightly less than 0.1% of women per year on MHT developing breast cancer. Let’s contrast that with another risk factor for breast cancer: age of pregnancy. Giving birth after the age of 35 is associated with a 40% increased risk of breast cancer compared with giving birth before the age of 20. If preventing breast cancer is the goal, why target only women after menopause with terrifying headlines?

The most effective medical therapies for hot flushes are estrogen, some antidepressants, and some antiseizure medications. As a doctor, I knew—despite all the claims on social media and various wellness sites—that diet, acupuncture, wearable magnets, and supplements were either ineffective or unproven. And on top of that, some of these so-called alternative therapies have risks. Especially supplements, which are unregulated and can sometimes contain hormones or antidepressants—medications that shouldn’t be taken without appropriate supervision.

I also practiced cognitive behavioral therapy (CBT) for hot flushes. There is good evidence to support its use here given the connection between hot flushes and anxiety; there are some shared connections in the nervous system that explain the overlap in symptoms, which may be why some medications that can treat anxiety can also improve hot flushes. Some might call that complementary or alternative medicine, but if it’s proven to be effective—which CBT is—then, for me, it’s just medicine.

For many women—women like me—menopause isn’t just about the bothersome symptoms. I knew my family history put me at high risk for osteoporosis. My mother began developing fractures in her 50s. She was likely in menopause by her early 40s, but such was the cloak of shame at the time that I can only approximate her age based on what I remember about her seemingly constant yelling at my father for shutting the windows.

Like many women, my mother’s osteoporosis was ignored. When I suggested she get screened for osteoporosis, she was told she didn’t need it. When I suggested she start hormone therapy treatment, she was told she “didn’t want that”—and that was even before the public concern surrounding estrogen. As women age their health concerns are often ignored as women themselves are expected to fade away into oblivion. After a miserable final 10 years with fracture after fracture, she died at age 86 from osteoporosis, having spent much of those final years in pain and in hospitals.

Estrogen prevents the accelerated loss of bone mass characteristic of menopause, so I knew it was the right choice for me to treat my hot flushes and protect my bones. I opted for estradiol, which is the main type of estrogen made by the ovary before menopause. While all pharmaceutical grade MHT is low-risk, transdermal estradiol is the safest option as it’s not associated with an increased risk of blood clots, so that’s what I chose. To protect my uterus, I chose an oral form of progesterone, as it is associated with the lowest risk of breast cancer (and even then, research shows the low risk seems to only start after several years of therapy).