DR MARGARET MCCARTNEY: The menopause isn’t just some ‘problem’ that can only be solved with HRT

HRT — hormone replacement therapy — is hardly out of the news.

From falling out of favour in the early 2000s, in the past few years its rise has been unstoppable — in 2022-2023 the NHS handed out 47 per cent more HRT prescriptions than the previous year.

It’s hardly a surprise, given the amount of publicity, celebrity endorsements on TV and social media, and the claims made about it. There’s no doubt that HRT is a very effective treatment for the classic menopausal symptoms of hot flushes and night sweats. However, promises on social media go way beyond that.

They offer great skin, ‘vitality’, ‘new energy’, relief from anxiety, ‘brain fog’, muscle pain and fatigue. Instagram is full of mid-life women looking fantastic and endorsing HRT. Closer to home, presenter Davina McCall has said that being on HRT is ‘going to kind of provide me with a bit more protection [from Alzheimer’s] than it would if I wasn’t’.

The subliminal message is that menopause is a medical problem and it needs to be treated.

Now a series of articles in The Lancet, by a group of eminent researchers in women’s health, has called for more nuance over the menopause and ways we treat it.

Even the name ‘hormone replacement therapy’ implies that women are deficient — the researchers refer to it as ‘menopausal hormonal therapy’.

Significantly, they say that ‘commercial companies and individuals with vested interests have over-medicalised menopause’ and that ‘framing of this natural period of transition as a disease of oestrogen deficiency, that can be eased only by replacing the missing hormones, fuels negative attitudes to menopause and exacerbates stigma’.

I have to agree. I remember, years ago, women rightly being annoyed when told by their doctors that every last symptom they had was down to ‘their hormones’, when actually they had other conditions that weren’t being investigated. We seem to have come full circle.

Some women clearly do have a difficult menopause, with severe and multiple symptoms, and experience great benefit from HRT.

But there are also women who are disappointed by it and find it doesn’t live up to some of the claims made on social media.

There are also plenty of other women who don’t feel the need for any treatment, or who can’t take HRT (for example, women with breast cancer), wondering whether they are condemning themselves to dementia or a heart attack by not putting on the patches.

The question is how to ensure women get high-quality information that isn’t biased or overpromising what HRT can deliver.

Last year, following its own inquiry, the All-Party Parliamentary Group (APPG) on menopause published a manifesto. It included a call to financially incentivise GPs to diagnose menopause and to license a female-specific testosterone (currently women prescribed testosterone have it on an off-label basis as there isn’t a female-specific product licensed in the UK).

But financial incentives for diagnosis can have unintended consequences, such as ‘diagnostic overshadowing’, where other conditions are not fairly considered.

And imagine thinking that your doctor was only considering diagnosing menopause in order to earn money from your diagnosis.

As for testosterone, the APPG said there is ‘some evidence’ it will treat fatigue and ‘brain fog’ — but an independent review in 2019 did not find proof for this. It came as no surprise to me that the APPG’s inquiry and manifesto were funded by drug companies — including Astellas, Bayer and Theramex, which either make or are developing medications for use in menopause — with both researched by Dentons Global Advisors (which has numerous pharma clients).

None of this means HRT doesn’t work, but it does risk women being oversold a treatment that comes with the risk of side-effects and won’t do what is promised.

Menopause can end up presented as a simple problem to be solved — a menopausal woman is deficient in hormones and therefore needs them replaced — rather than a complex, nuanced picture (some women will benefit from hormones, others will not; some symptoms may be caused by menopause, others not; some women will have few symptoms, others will not).

Take the social media backlash to draft guidance on menopause issued last year, when the National Institute for Health and Care Excellence (NICE) suggested cognitive behavioural therapy (CBT) can help some women manage symptoms. This drew complaints that symptoms were being dismissed as ‘all in the mind’.

Yet there is good evidence that many women find CBT useful: it’s already used for other conditions, including chronic pain, and is about giving people helpful ways to deal with symptoms — not saying their very real symptoms are ‘just’ psychological.

There should be room for choice in evidence-based approaches, but the current HRT-menopause axis doesn’t allow for this.

Meanwhile, it’s clear menopause is driving a growing industry keen to sell products allegedly designed for fiftysomething women. Instagram is full of supplements, skin and hair care, all purporting to deliver menopausal benefits.

I’ve spoken to several young women who are watching the coverage with a quiet dread, afraid of their menopause to come.

Yes, some women have a terrible time. But we owe it to women of all ages to make it plain that for some it’s a liberation, free from periods and the need for contraception — and for others, symptoms are mild and it’s rather a non-event.

Women are still losing out — we might have more ‘awareness’ of the menopause but I don’t think this has come with better information.

So how do we make better choices? Seek independent information — from organisations that don’t have vested interests, aren’t funded by pharma and who won’t make money by selling you stuff.

I also look for information where I can see the cons and pros fairly laid out — miracle cures don’t exist.

Finding a way through hype and sales pitches is not for the faint-hearted, but if there ever was a need to try to find unbiased medical advice, it’s here.

Dr McCartney is a GP in Glasgow and a senior lecturer at the University of St Andrews.