Women's health
Hormone therapy at midlife: indications, evidence and the cautions that get skipped
Menopausal hormone therapy was withdrawn from a generation of women on the strength of findings that were later substantially reinterpreted. The correction has produced its own excesses.
Dr Priti Nanda SibalCo Founder and Ex President, IAFMThe history here is worth knowing, because it explains why patients arrive either frightened of hormone therapy or convinced it will resolve everything. Both positions were manufactured, and neither reflects current understanding.
What follows is how I approach the subject with women at midlife, including the parts that are commonly left out.
Where the evidence is reasonably clear
Hormone therapy remains the most effective available treatment for vasomotor symptoms, meaning hot flushes and night sweats, and for genitourinary symptoms of menopause. It has established benefit for bone density.
Risk profile depends substantially on age at initiation, time since menopause, the specific preparation, the route of administration and whether a progestogen is required. Initiation closer to menopause in a woman without specific contraindications carries a different profile from initiation many years later. These distinctions were absent from the public conversation for two decades and they matter more than almost anything else in the decision.
What requires more caution than it usually receives
Several claims circulate widely with less support than their confidence suggests.
- That hormone therapy is a general treatment for ageing, energy, mood, cognition or body composition, which goes well beyond established indications
- That compounded preparations are safer or more natural than regulated products, when they are less consistently dosed and less well studied
- That salivary hormone testing should guide dosing, which is not supported and frequently misleads
- That symptoms alone always require hormonal explanation, when thyroid disease, anaemia, sleep disorder, depression and iron deficiency present similarly and are more easily missed
- That treatment can be initiated without discussing personal and family history of breast cancer, venous thromboembolism, cardiovascular disease and liver disease
The term bioidentical adds to the confusion, because it is used both for regulated products with molecular structures identical to endogenous hormones and for unregulated compounded mixtures. Those are not equivalent, and patients usually do not know that the same word covers both.
How the consultation should run
Symptoms first, in detail, with their effect on sleep, work and relationships recorded. Then differential diagnosis, because not every midlife symptom is hormonal. Then history and contraindications. Then a discussion of options including non hormonal ones. Then, if therapy is appropriate, the lowest effective dose with a defined review interval.
Review is where practice most often fails. A prescription issued and never revisited is not treatment, and dose adjustment over the first year is usually necessary.
What I tell patients
That hormone therapy is a legitimate, effective and reasonably well studied treatment for specific indications, and that they were probably denied it unnecessarily if they were treated in the previous two decades. That it is not a treatment for ageing. That the decision depends on their history rather than on a general rule. And that anyone offering it on the basis of a saliva test and a symptom questionnaire, without taking a proper history, is not practising carefully.
Women at midlife have been served poorly by both the alarm and the enthusiasm. Accurate, individualised information is the correction, and it takes longer than either.
This article is written for education and professional discussion. It is not medical advice and it is not a substitute for consultation with a clinician who knows your history. Nothing here should be used as a reason to stop or alter prescribed treatment without the involvement of the doctor who prescribed it.