Reply to the Lancet Opinion Piece 05/03/2024
At Hera Menopause and Women’s health, contrary to a recent opinion piece in the Lancet released on Tuesday, I can tell you, midlife is NOT being overmedicalised! In fact, just today I recommended a lovely patient come off MHT (menopause hormone therapy aka HRT) altogether as after a few months of trial, it simply was not working for her. We are now finding other ways to address her inherited risks of osteoporosis and heart disease, ensuring she keeps up with her screening and lifestyle practices. I am confident she will live and age well. Women from all walks of life come to see us, seeking to do the best for their health- particularly in the areas of prevention. Some are totally incapacitated in their vocations and floored by their menopause symptoms, others less so, but want to actually take charge of their health. They need some guidance as how to thrive through their non -fertile period free years and beyond. They do not necessarily feel that menopause ‘is being depicted a negative way.’ I left general practice because I felt a lot of the care had become over -medicalised, and I no longer had time to make a real difference. Preventative health seems to have become a lost art in general practice, not by fault of the GPs themselves, but the system.
Women want to be seen, heard and validated for who they are and what they do. They deserve to be respected as well-informed participants in the decision making about their own bodies and minds. Are we dishing out MHT blindly like lollies to a toddler? Certainly not! The success of our model of care in specialized menopause medicine is that women are given the TIME to determine what matters most to them.
That’s right -in 2024 women actually have a choice and are able to make informed decisions in partnership with their health care provider. Surely, we are past the era of the dictatorial ‘do-as-I-say or else’ doctor.
Wholistic menopause care means assessing a woman’s symptoms, against her background of gynaecological, medical, psychiatric and family history. It’s assessing her benefit versus risk of commencing MHT and offering alternative options as well. Most of all, it’s empowering her to get back to the most important things of all: optimizing her diet, exercise and social connection. In many cases in my experience, however, women can’t even contemplate these things without the aid of MHT. It would be naïve to think that a lifestyle prescription on its own would be enough to allow most women to manage the symptoms of the menopause.
MHT has been under more scrutiny and conjecture than any other pharmaceutical offering. The recent Lancet piece acknowledges that MHT treats vasomotor symptoms and prevents fractures but the ‘evidence that it helps other symptoms are lacking.’ Anecdotally, I beg to differ. Dry skin, severe joint pains and muscle aches seem to mysteriously disappear when MHT is properly established.
As doctors, we are happy to prescribe a myriad of other medications without batting an eyelid. SSRI antidepressants as well as PPI acid blocking medications cause a reduction in bone density with long term use. Chronic use of Gabapentin often used as a non hormonal treatment for vasomotor symptoms might impact brain health over time. We don’t seem to mull over or publicise these facts.
The Lancet opinion piece states that there is ‘no robust evidence’ that mental health disorders increase over the menopausal transition. Our fear is that this literature review is based on papers from yesteryear, not acknowledging the large hiatus in research in the 20 plus years that HRT was demonised. Thankfully, Professor Jayashri Kulkarni is hard at work providing evidence for what see in day-to-day practice. We have seen time and time again, women with profound reproductive depression, and intrusive anxiety around menopause who previously have never suffered mental illness. Once again, these symptoms are alleviated with timely initiation of MHT. At the coalface of menopause medicine, we see more dramatic improvements in a patient’s wellbeing with MHT in the majority of patients than any other drug. We beg to differ that MHT is more than ‘slightly effective’ for symptoms in menopause in real life practice including with regards to mental health.
We do however agree with the Lancet authors that Menopause requires more evidence based awareness, more support and education and more research going into the future particularly for women in rural or impoverished areas, unable to access care or information. We might surmise that they sail through menopause far better than we do in the West, but perhaps their voices are not well enough broadcast for us to hear. We also agree that early menopause sufferers and menopause after cancer patients certainly do not receive optimal care.
Our fear, with the release of this article, particularly on the eve of International Women’s Day, is that the ghosts of the 2002 may once again spook all women, keeping them shackled to the menopause symptoms touted as ‘normal.’
Written by Dr Sunita Chelvanayagam, Menopause Specialist and Co Founder of Hera
