For decades, physicians have used the term “hormone replacement therapy” or “HRT” to reference the process of providing doses of estrogen and progesterone to people experiencing perimenopause and menopause. This medical therapy has improved with time, and the way it’s administered has changed dramatically. Why, then, are health care providers cautious to prescribe this life-changing therapy to people with menopausal symptoms?
As a menopause expert and practitioner, I strive to be both clinically accurate and patient-centered in my language, which is why I advocate for using the terms “hormonal therapy” (HT) or “menopausal hormone therapy” (MHT) rather than HRT, which has controversial connotations.
The fear behind hormone replacement therapy
Despite years of improvements and successful treatments, confusion and lack of education around hormonal therapy for menopausal symptoms persists. A search for the terms “hormones” and “therapy” online will result in stories detailing the pros and cons of HRT and its confusing history.
HRT fell out of popularity in the early 2000s due to media overreaction to clinical results. As a result of this backlash, the menopause treatment that clinicians use now — which I refer to as MHT or HT — is notably different from the treatment that physicians used pre-2002, but the confusion around this life-changing therapy remains, which is why providers must prioritize clarity in conversations with their patients.
Clinicians have prescribed varying doses of estrogen for people experiencing perimenopausal and menopausal symptoms — including hot flashes, mood changes, and sleep issues since the 1960s. And before 2002, health care providers often used higher doses of hormones regardless of the patient’s symptoms.
In a 2002 study, the Women’s Health Initiative (WHI) found that there was a slightly increased risk of coronary heart disease, stroke, blood clots, and breast cancer for women in the study receiving HRT. The absolute risks were low, and women in the study also experienced extra benefits, including reductions in bone fractures and colorectal cancer.
But it was too late to change the narrative. The ensuing media storm over the perceived elevated risks of HRT caused many physicians to stop prescribing hormones to patients, and people were cut off from an incredibly helpful therapy. This resulted in a generation of providers — including medical students, residents, board certified MDs and DOs, and HCPs — knowing very little about menopause treatment.
Over the next 13 years, the WHI and other research groups reanalyzed the study. In this review, they focused on the age patients started taking hormones and the length of time since patients’ final menses (menopause). They found that with modifications, the benefits associated with hormone therapy outweighed the risks.
Refining hormone therapy
Since 2002, medical providers have resumed prescribing hormone therapy with even lower risks. The solution? Starting patients on hormone therapy earlier and modifying the dose to fit each person’s individual needs. In fact, people within 10 years of their final menstrual period (age 51 is the average age of menopause in the United States) who start on appropriate, often low doses of hormone therapy have benefits beyond treating menopausal symptoms, including preventing bone loss and fractures and reduced risk of heart disease.
Providers today are not replacing estrogen when they prescribe hormone therapy. “Replacement” implies that clinicians are trying to return people’s estrogen levels to that of their reproductive years. MHT or HT provides therapeutic doses, like any other medicine. Providers can give patients individualized doses and deliver these doses orally, transdermally, or vaginally.
The only time a clinician would actually be “replacing” hormones with higher levels is in the specific case of people experiencing premature menopause (when someone has their last period before the age of 40). In most cases, these younger patients should stay on HRT until they turn 51, the average age of menopause.
Hormone therapy’s far-reaching benefits outweigh the risks
Hormonal health is a critical piece of aging, and menopausal hormone therapy is a low-risk treatment that drastically improves the lives of many people. Clinicians must know how to talk about HT in order to reduce the fear of this modern treatment alternative.
How menopause affects the workplace
In the U.S., 20% of working people experience menopause. Perimenopause begins between the ages of 45 and 55, and symptoms can last up to 14–20 years for some people with a median of 7.4 years. The average age of retirees in the U.S. is 61. That’s a possibility of 16 years of discomfort at work because of menopausal symptoms. In one survey, 22% of women said they have considered early retirement because of a lack of employer support or resources during menopause.
The loss of senior female leadership and the productivity cost to companies are staggering, and they will continue to impact generations of women if healthcare providers do not understand menopause treatment.
Prioritize updated information and terminology
As a practicing clinician, I want people to have correct, updated information, which means I prioritize accurate terminology in my practice. These days, clinicians prescribe hormone doses to treat symptoms and individualize menopausal therapy. Informed healthcare providers start patients on the appropriate dose of estrogen, monitor patients’ symptoms, and adjust the dosage accordingly. One of the real tragedies related to misinformation about hormonal therapy is that even low doses of estrogen can preserve bone density and reduce hot flashes in menopausal women.
A two-pronged approach to menopause education
As a physician and educator, I practice a dual-prong approach: educating both the medical community and patients. The good news is that people are getting curious. Many people who come into my office ask if menopausal hormone therapy is an appropriate option for their symptoms. Because the benefits of hormonal therapy outweigh the risks for most, clinicians must be prepared to discuss treatment options with their patients. This only works if providers understand the numerous treatment options, and that starts with using correct terminology. Newly trained providers have resources such as the North American Menopause Society Menopause Practice textbook and many excellent medical websites, such as www.menopause.org.
While there is a long way to go to close the educational gap, medical education — including medical school, allied health education, and professional development — specifically focused on the treatment of perimenopausal and menopausal patients, can drastically improve the quality of care for those experiencing menopausal symptoms.
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