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hotflash inc.: should people in menopause be on hormone therapy to prevent disease?

depending on who you talk to, hrt is either loaded with health risks or it prevents almost any illness. how do you know who to believe?

by ann marie mcqueen

published nov 21, 2022

last updated feb 13, 2023

5 minute read

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5 minute read

join the conversation

hormone replacement therapy is a developing story

menopause hormone therapy, a.k.a. hrt, has become another polarizing topic of our times. getty

recently, i had an awkward conversation with someone who is in the business of selling menopause hormone therapy. she thought i should be on it myself and spend more time promoting it for my followers; she said it helped her feel great, was the key to looking younger, and helps to prevent all sorts of diseases. i wasn’t surprised: i hear and read the same thing almost every day. i’m just not sure, as a woman going through a pretty epic perimenopause, if it’s right for me, right now. and as a journalist, i’ve learned to be discerning about who’s on the other end of eternally sunny, silver-bullet sales pitches.

unfortunately, menopause hormone therapy, a.k.a. hrt, has become another polarizing topic of our times. on one hand, you have the lingering chill and fear from overblown cardiovascular and breast cancer risks that came out of the deeply flawed women’s health initiative hormone therapy trials in 2002. on the other, you have a major push for hormone therapy, not just to treat symptoms, but as a cure-all and preventive for almost everything that might ail us. and in the middle, you have a lot of doctors who don’t know much about menopause treatment, and people going through it who don’t know who to believe or where to turn.

evidence shows hrt decreased risks for type 2 diabetes

the north american menopause society (nams) released updated guidelines for doctors over the summer, which helps cut through some of the narrative.

the nams guidance said there wasn’t enough evidence to recommend hrt as a preventive for dementia, a big point in this debate with dementia cases in women outnumbering men two-to-one. nams cited evidence that hrt does prevent bone loss and fracture, along with demonstrating decreased risks for everything from belly fat to colon cancer, type 2 diabetes, cardiovascular disease and all-cause mortality. (there is some evidence that estrogen is beneficial for skin, not enough for hair, nams said)

nams generally sticks to a “with symptoms” criteria for prescribing hormone therapy, which is backed up by the u.s. preventive services task force, an independent and volunteer panel of national experts in disease prevention and evidence-based medicine, that does not recommend menopause hormone therapy for primary disease prevention in their latest systemic evidence review recently published in jama network.

according to uspstf, “menopause typically occurs around age 50 years, and in the years following menopause, the rate of many chronic conditions, such as heart disease, stroke, diabetes, dementia, cancer, and bone fractures, increases. while aging may be the main cause, there has been some uncertainty about whether menopause also contributes to the development of these conditions. although menopausal hormone therapy can help treat menopausal symptoms, whether it helps prevent development of chronic medical conditions is unclear.”

it’s the “unclear” part that gets me. i’ve interviewed dozens of menopause experts on my podcast over the last two years, and i always ask them the same question: do women managing our symptoms need to be on hrt for prevention of disease?

the answer is generally no, with the latest this summer a vehement “absolutely not” from university of melbourne obstetrics and gynecology professor martha hickey, who has extensive experience in menopause research.

but still i wonder, isn’t it possible that the evidence will overwhelmingly tilt toward prevention and longevity in the future, and that by waiting for it, we might be missing out now? after all, as ahead-of-the-curve canadian naturopathic doctor lara briden writes in her book, hormone repair manual, the idea of “good gut bacteria” was once derided as pseudo-science — yet now, everyone is obsessed with the microbiome.

not every woman needs hrt

she thinks the strongest argument for preventive estrogen lies in mitigating insulin resistance, which impacts one in two of us over 40. and that those of us who come out of menopause transition recalibrated, with the proper metabolic flexibility and brain energy, would not see the same benefit. in other words, some of us will be fine without menopause hormone therapy, some of us need it — that’s why the findings about long-term disease risk are so mixed.

i put the prevention question to that rare practitioner who works in both the mainstream and integrative worlds, dr. suzanne gilberg-lenz. an obstetrician-gynecologist, board-certified in integrative and holistic medicine and a clinical ayurvedic specialist practising in beverly hills, she’s also author of the new book menopause boot camp: optimize your health, empower your self and flourish as you age.

“this conflict is my lifelong challenge,” she said. “i appreciate and deeply respect the work of nams and am a member, but i also recognize that organizations adopt change slowly. i am aware that critics of anything but the ‘correct, empiric’ methodology would disagree with me and state that i am considering and promoting approaches that are not ‘evidence-based.’”

her advice is to educate ourselves and advocate for ourselves, and know that not all practitioners have the same training or outlook.

“critical thinking is a requirement of clinical practice, and adulthood, for that matter,” says gilberg-lenz.

the hardest part of all this is that it’s a developing story, and we are in the middle of it. that’s why i’m taking my time to figure out whether hormone therapy is right for me, and that’s all i would ever advise anyone else to do.

it never feels good, or right, when one person puts another on the spot by second-guessing their health decisions, no matter what their motivations are. we didn’t have the context for that kind of judgment when we were younger, and i don’t think we have it now.

ann marie mcqueen is a journalist with 25 years of experience covering health, wellness, science and more, and when she realized she was in perimenopause five years ago, she decided to make this transition her beat. she has since become a global expert on the subject through her platform hotflash inc., where she helps people navigate the gap between transitional and holistic treatments with evidence and experience-based research. she will be writing regularly on all things related to menopause and mid-life.

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hotflash inc.: should people in menopause be on hormone therapy to prevent disease?

depending on who you talk to, hrt is either loaded with health risks or it prevents almost any illness. how do you know who to believe?

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hotflash inc.: should people in menopause be on hormone therapy to prevent disease?

depending on who you talk to, hrt is either loaded with health risks or it prevents almost any illness. how do you know who to believe?

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