Squiz Shortcuts Series: Navigating menopause with HRT

Welcome to our Squiz Shortcuts Series on menopause and perimenopause. Today, we’re diving into HRT…

There's been a whole lotta confusion and anxiety around HRT - or Hormone Replacement Therapy - mainly because of a trial being pulled back in 2002 because of concerns of an increased risk of breast cancer. Except that wasn’t the case at all, and a lot of experts have spent the next couple of decades trying to stop the panic.

So, for the final instalment of our 3-part series on perimenopause and menopause, Professor Susan Davis from Monash University - perhaps the person who knows more about HRT than anyone in the country - is going to help us tackle:

• why there’s been such controversy around HRT

• the different types of hormones and treatments

• and if every woman going through menopause should be taking it

Prefer to watch or listen to this?

You can listen to the podcast here or tune in on YouTube - and hit subscribe while you’re at it. And scroll on for the highlights of our conversation.  

Unpacking HRT with Professor Susan Davis

How did our collective thinking about HRT get so messed up?
I think we have to go back to the 1990s when the study called the Women’s Health Initiative was set up with the belief that oestrogen prevented heart disease. And after 5 years, it looked as though the women getting oestrogen and progestogen had an increased risk of breast cancer, so someone pressed the panic button. There was this extreme global panic … all sorts of confusion. And it became a taboo topic to the point that if I suggested HRT to a patient, they almost ran out the door. But you know, some of us worked through this, and others basically stopped prescribing.

So where are we at today?
Unfortunately, what we've got in Australia today is women who probably don't need hormone therapy taking it because they're worried that if they don't, they might get dementia. And there are vast numbers of highly symptomatic women who are not taking hormone therapy because they’re scared of it, or the doctor doesn't know how to prescribe it, or they don't think their symptoms are bad enough. So we've got a bit of a mess at the moment.

Sigh… So who could be helped by this treatment?
In a paper we just published, looking at over 8,000 women in Australia, the predominant symptom is hot flushes and night sweats. And women who have hot flushes and night sweats tend also to have sleep disturbance, anxiety, mood changes, brain fog, and weight gain, and they all track with the hot flushes and night sweats. So that's the really screaming symptom that their hormones are all over the shop or insufficient.

Tell us about those who don’t need it…
What we know is that there is this phase of perimenopause - that's when women are still intermittently ovulating. Their ovaries haven't given up. And with those swings in hormones from the off/on action of the ovaries, women are experiencing what they would mostly describe as that brain fog, poor memory, etc.

Yep, we hear that a lot from our mates…
And we know that settles down once women get through the menopause transition into the postmenopausal years. But it's really terrifying if you keep walking into a room and you can't remember why you've come in - or you go to say “can you pass me the cheese?” but you can't think of the word cheese… What is clear is that not a single clinical trial has shown that compared with a placebo, oestrogen therapy actually fixes that problem.

What we’re hearing from you is that we should take with a grain of salt all the people on the socials pushing natural oestrogen for every woman…
Look, every woman should have the conversation with their doctor. So if you came to see me and you were having hot flushes, night sweats, irritability, anxiety, and sleep disturbance, I would discuss with you going on hormone therapy. And the thing that fixes those symptoms is oestrogen. 

But if you don’t have those things?
If you say to me, all my friends are going through menopause, I haven't had a period for a year, but I've got no symptoms - the next thing I would do is a bone density scan, because we know that you lose about 6-8% of your bone when you go across the menopause transition, even if you do not have symptoms. I would want to see if you are at risk of progressing to low bone density and whether you should be on oestrogen to protect your bones. 

What’s involved with being on oestrogen?
There is a huge push for everyone to use oestrogen gel and progesterone because they're considered so natural. The problem is that a lot of women entering the late perimenopause or whose periods have stopped for over a year and are postmenopausal, are still making some oestrogen in their bodies. And so the lining of the uterus can still be a bit thickened, and sometimes you do need to use a synthetic progestogen for a few months to get on top of preventing unscheduled erratic bleeding.

So it’s not a one-size-fits-all?
Some people do not absorb the gels or patches and need a tablet. Some people do not cope well with the progesterone. They get either too sleepy - so the next morning they're sort of hungover - or they get bloating or fluid retention with it. So it's not right for everyone. What's really important is that we have a whole suitcase full of options. 

What’s the go with all the hype over testosterone for women?
Testosterone's being promoted as the magic bullet that's going to basically fix fatigue, bone health, energy, sexual function, muscle function, and on and on. And I've probably published the most studies in this space. We know testosterone blood levels decline with age - they do not change with menopause.

Any studies you’d point to?
The best example of the placebo effect is 2 studies that involved a thousand women being treated with a testosterone gel placebo. They knew they had an equal chance of getting testosterone or the placebo, and the placebo was just as effective as testosterone for sexual function - even in women who knew they could be getting a placebo. Women should not be taking testosterone as a magic bullet to feel better.

It’s so hard to navigate the information and claims being thrown at us…
We really are doing women a huge disservice in this whole space. I think we're trying to promise women we can fix everything in their lives with hormones, and we can't. Life is very complicated. Getting your hormones sorted and alleviating those menopausal symptoms will help, but it's not going to fix everything.

How important is other stuff like sleep, nutrition, lifestyle?
I think what our study shows dramatically is that hot flushes and night sweats are really menopausal. You can hang your hat on that one. A lot of other symptoms women are presenting with might be exacerbated by menopause, but they're actually about other life factors.

Give us an example…
If you look at moderate to severe depressive symptoms, 27% of premenopausal women had those symptoms, and the highest rate in perimenopause was 32%. So women are coming into perimenopause, bringing in the fatigue, the sleeplessness, the moderate to severe depressive symptoms. But not everything is due to menopause.

And HRT probably can’t fix that…
No. I have patients who tell me “oh, I've been having trouble sleeping for 10 years”. Hormones are not going to fix that because the root cause has been present for the last 10 years.

What should we take out of that?
Be open to not thinking that everything is menopause. You've got to try to look at the root causes. Try to address your nutrition, sleep, and exercise.

The supplement that supports you through your menopause

Here's something worth knowing - WelleCo’s 79 global industry awards recognise their premium, plant-based supplements that help during menopause. Their range focuses on filling the nutritional gaps that can pop up during this stage, supporting your body through the changes with natural ingredients. It's not about replacing your current treatment, but adding an extra layer of support where your body might need it most. Check out the range here… Squizzers get 15% off with code SQUIZN15.

Onto our Recommendations

Reading - We really enjoyed The New Yorker's reflections on why menopause is having such a moment… You can bet you a few celebrities had just a little something to do with it…

Following - Professor Davis’s handy guide for GPs to help them when they are treating women in perimenopause and menopause. Check it out for yourself - and you can go armed to your next appointment with all the info…

Sharing - We reckon you’ll have a few people in your life who would benefit from the information we’re pulling together in this series. Please share this email with them, or if they’re podcast people, send them to the Squiz Today show on their podcasting app, and this episode is clearly marked in the feed.

Start this series at the beginning…