By Ann Marie McQueen
You don’t know what you don’t know.
If only more of the world remembered.
I was reminded on Tuesday when this dropped in the journal Climacteric: The 2023 Practitioner’s Toolkit for Managing Menopause.
This is the badly needed global handbook for doctors I didn’t even know existed, an update to the original published in 2014. (And although I only really discovered perimenopause in 2017, entered this space casually in 2018, and formally in early 2020, I should have.)
Menopause hormone therapy as a safe route for symptoms? Sure. Menopause hormone therapy for disease prevention and longevity? Maybe. Probably? One example of this is the work of a team that includes Dr Lisa Mosconi, director of the Alzheimer’s Prevention Program and of the Women’s Brain Initiative and an associate professor in the department of neurology at Weill Cornell Medicine, on hormone therapy and dementia prevention in midlife women.
They recently released a meta-analysis showing promising results her team is now testing in a clinical trial, focusing on estrogen.
It will be interesting to see how it bears out: observational studies, with their many confounders and biases affecting outcomes, have a way of unravelling in the face of randomization and blinding.
Meanwhile, we have doctors shouting to the rooftops about hormone therapy as a cure-all and preventative for everything. (Recently a physician told me ‘actually, treating symptoms is the icing. Prevention is the whole cake’. This week a doctor happily accepted the label “the Taylor Swift of menopause” for beating the drum, and another said ‘all women should get a trial of HrT’.) And so the pendulum is swinging from post-Women’s Health Initiative Study fear and avoidance right through awareness and acceptance to FOMO, based on hype. Neither is optimal.
Thank goodness there are level-headed practitioners keeping their egos and our expectations in check as they guide us.
I’d encourage you to be the CEO of your own health and read this 6,000-word toolkit for yourself. It’s open-source. (Don’t worry, I’ll report on it too).
What you get is a pragmatic, evidence-based roadmap led by Professor Susan Davis, a leader in the field of testosterone research, an endocrinologist and director of the Women’s Health Research Program in the School of Public Health and Preventive Medicine at Monash University Melbourne. Dr Davis is also a leader in research into testosterone in women, having published a review in 2021 (snippets available) in 2021. One place you won’t find her? On social media making wild and unsupported claims about it.
Anyway, this toolkit has been revised in accordance with published literature.
It was conducted via a systematic search of the largest medical databases for guidelines, recommendations, position and consensus statements on menopause published since 2015. It incorporated four independent reviews using standardized tools, evaluated 25 menopause guidance papers, and extracted recommendations for menopause hormone therapy and non-hormonal therapy that reached a level of “moderate” quality. They include fezolinetant, the drug for hot flashes approved by the Food and Drug Administration in the US, and the updated recommendations for hormone therapy (2022) and non-hormonal therapy (2023) most recently published by The Menopause Society in North America. Keeping in mind that treatment options and care levels vary around the world, the focus was to recommend “the minimum best care for all women”. This is important. It includes an algorithm to assess menopausal status, including in women who had a prior hysterectomy, endometrial ablation or who are using using a form of hormonal contraception.
This updated handbook has been endorsed by the International Menopause Society, Australasian Menopause Society, British Menopause Society, Endocrine Society of Australia and Jean Hailes for Women’s Health.
Top line, for when we get confused:
“The menopause is a physiological process experienced by all women who live beyond midlife. The perception and experience of the menopause transition and years post menopause is unique to each woman and will be influenced by the age at which menopause occurs, whether it is natural or iatrogenic, past and current physical and psychological health and well-being, and ethnicity, environment and culture. The use of hormonal or non-hormonal therapy will be determined by symptom severity, weighing of benefits and risks, and each woman’s expectations and wishes.”
No mention of disease, deficiency, syndrome or pathology.
Menopause is defined as “the permanent cessation of menstruation in a non-hysterectomized woman”, and, acknowledging that many people have already experienced cessation of menstruation for other reasons, states: “menopause is the permanent cessation of ovarian function”.
When it comes to scientific evidence supporting the use of menopause hormone therapy that can reasonably be applied to all women, the current use-cases are much more narrow. This is essential to note, in light of one truth rarely mentioned by HrT maximalists: hormone therapy is a drug that comes with a range of possible side effects, which we might better think about as “direct effects” that were renamed at some point in history to soften the worry of their impact on the consumer.
Look, when it comes to official guidelines, I get frustrated too. There are all sorts of things I swear that helped me through perimenopause I won’t find endorsed in any scientific journal. Guidelines like this recommend against compounding, a bespoke option that helps millions of women, including those who don’t do well on mass-produced HrT. DHEA is not recommended (it never is). Listen to Arizona-based Dr Angela DeRosa talk about her decades of work with testosterone on the podcast (and any woman whose life has been changed by taking it) and you can see how the evidence doesn’t match the reality. It’s far past time to separate out progesterone (bioidentical, biosimilar, most like what our body produces) from progestogens, which are less like what our body produces, and carry the risk signals. That’s not done here, and it needs to be. It doesn’t even mention gut health or microbiome, which shows you how behind the evidence really is.
The limits of science – and the deeply flawed clinical trial process – are precisely why I designed Hotflash inc based on evidence, experts and experience.
It’s also so tempting to use “science” in whatever form it comes in to back up beliefs when it’s convenient, and ignore whatever runs counter them when it’s not. It’s called “cherry picking”. (I never want to be one of those “she would say that” people. We have too many of them)
Personally, I am perched right on top of the fence on this: Radically healthier leaving 2023 than entering it, feeling pretty great without HrT, but also a long-time mini-biohacker obsessed with living well and longevity. And although I’m in menopause now, I’m still struggling with babying my newly healed gut, some executive function and mood fluctuations (even though these guidelines do not recommend HrT for depression) and wondering whether to watch and wait or start experimenting. I’m also facing a supply chain shortage and insurance issues and budget considerations and a ob-gyn who wouldn’t prescribe until now. Then there is the cardiologist who just pronounced me a healthy woman and, when I asked her about hormone therapy, said “why would you expose yourself to side effects for something you don’t need?”. Not to mention the vast majority of practitioners I’ve interviewed who don’t recommend it beyond symptoms.
I’ve also got time: I’m right at the start of the 10-year window of opportunity, having gone through menopause in August. I might try it; I just don’t know. What I do know, is that soooooo many women have lived and are living long vital healthy lives without hormone therapy, and that the basic tenets of health never really change: movement, nourishment, avoid smoking, drinking, stress and other inflammatory things, minimize stress, and connect with other humans.
Our bodies were designed to go through this, no matter how rocky it gets.
Bolstering that truth, we now have the first indications that contrary to popular belief, most mammals go through it too.
Keep in mind, outside the noise, we already knew this: Menopause hormone therapy is not right now recommended by any guiding menopause body in the world for prevention of dementia or cardiovascular disease, cancer or all-cause mortality; the scientific evidence is not at a level to support any of those claims, no wonder what anyone says. It is recommended for bone health, but the benefits are only realized for the duration of treatment.
Despite all the wishing in the world, and the reality that nuance like this does not make a compelling hook for a TikTok, nothing about that changes with this toolkit.
And that’s why – I’m just guessing here – you might see or hear precious little on it from some of the biggest voices in the game.
Find out more about Ann Marie’s work at HotFlash Inc. and on Substack.