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Michelle Peate should have a big advantage when confronting the question of when, if, and what hormones to take as she moves into perimenopause.
The expert in how people make choices in reproductive health treatment is well-informed about what women may experience years before their last period, but the 46-year-old is still confused when it comes to the trending issue of hormone replacement.
Like many women around her age, Peate is hearing online and through word of mouth about the many claimed benefits of menopausal hormone therapy [formerly known as HRT], for those wanting to avoid everything from short-term sleep and mood problems, to protecting long-term heart and brain health.
Some of these are backed by research, others remain controversial and have been dubbed misinformation.
“It’s not just on social media, my friends who are older are telling me, ‘You should get on it now, before you have any symptoms’,” says Peate, an associate professor and researcher on how people choose reproductive health treatments.
“A lot of my feed is really about getting onto it earlier, ‘even before you hit menopause, in this perimenopausal stage, get on MHT ’,” she says.
“A lot of it is around reducing the risk to bone health and cognitive stuff as well … There’s this constant bombardment almost creating a fear of what menopause will be like – ‘go get a patch’ is what I’m seeing constantly.”
Debate flared again earlier this month when the World Health Organisation made new recommendations about prevention of dementia.
The body, which conducted a metanalysis of research to update its dementia prevention information, found no clear evidence to recommend for or against the use of MHT to prevent cognitive decline or dementia in women under 65.
For those over 65, it conditionally recommended against MHT to prevent cognitive decline or dementia.
The findings are at odds with widespread messaging by influencers who have promoted an early window of opportunity to start MHT and stop brain function decline. Some continue to stress that observational data backs their theory that starting younger women on MHT including trans-dermal oestrogen supports long-term brain health.
Australian researcher Professor Martha Hickey, chair of Obstetrics and Gynaecology at Melbourne University, was clinical expert on the WHO panel which examined MHT and dementia.
“We looked at all the evidence on MHT and not only dementia but mild cognitive impairment that can lead to dementia, and we found nothing, at any age,” she said.
“Younger women who go through menopause are told often to take MHT to protect their brains; we expected to find some evidence for it, and we didn’t.”
Hickey runs menopause services at the Royal Women’s Hospital in Melbourne and sees women who, like Peate, are struggling with information, or misinformation, overload on hormones.
“What’s coming out on social media is getting worse,” says Hickey.
“The way it’s impacting me as a clinician is people are confused. They’ve seen one thing on social media and someone they speak to or a clinician says something different. This is a relatively new phenomenon.”
She is concerned that younger women are being placed on MHT to address a vast array of presumed symptoms of perimenopause when research has not yet revealed the safety of this.
“Earlier access to MHT is a huge problem when you look at the safety and efficacy of MHT, meaning does it work and is it safe? Almost all the evidence comes from post-menopausal women because pharmaceutical companies funded a lot of those trials and excluded perimenopausal women,” Hickey said.
“The fact that younger women are being given it is quite worrying.”
Professor Susan Davis, head of the Monash University Women’s Health Research Program, and of the Alfred Hospital’s Women’s Endocrine Clinic, said that while MHT can help reduce perimenopausal brain fog, MHT has not been found to boost cognition after menopause.
“We and another group have done clinical trials to see if giving estrogen in early post-menopause improves cognitive performance, and it doesn’t,” Davis said. Several other clinical trials had made the same finding.
“Although there were initially big observational studies that suggested women who took HRT [now MHT] had less dementia, there’s been nothing in clinical trials that has shown that to be solid.”
“The working belief is that the symptoms women experience in perimenopause are a combination of fluctuating hormone levels, hot flushes, night sweats and disturbed sleep.”
Menopause advocate Sandy Kincaid said the reason many women experienced confusion about when to start MHT and what it could do was because doctors were not trained well enough to provide accurate, up-to-date information.
She defended high-profile medical influencers, saying that they were helping women to interpret research. “If we’re not getting the good information from our doctors, what in the hell are we supposed to do?” Kincaid said.
‘We can’t wait for research to catch up to us.’
Menopause advocate Sandy Kincaid
Younger women from their late 30s and 40s on should have access to MHT if they feel they need it, so long as the benefits outweigh the individual risks: “We can’t wait for the research to catch up to us,” she said.
Dr Kath Whitton, a gynaecologist and reproductive endocrinologist on Sydney’s north shore, said preventive use of MHT was a hot topic, and her patients often reported more benefits to being on MHT than prescribed symptom relief.
“It’s a tough space [for women to navigate] because there is so much noise out there online and it’s hard to get accurate information,” she said.
“There is a lot of kind of overpromising on the benefits, so we’ve really got to tread carefully I think,” Whitton said.
Menopause mentor and advocate Jacqueline Pascarl said the WHO analysis did not reveal what types of hormones women in the research it analysed were using, or the dosages and mix.
“I would say that the data is not fully formed,” she said, describing the studies analysed as antiquated and based on synthetic MHT, not “modern bio-identical formulations now available”.
Pascarl went on MHT after surgical menopause in 2009 and has no intention of ever stopping it.
“At 63, my physical health is better, my mental health is strong, and my cognitive abilities allow me to still work full-time and remain mentally alert,” Pascarl said.
As for Peate, she is not yet convinced she should start MHT before symptoms set in.
“What makes me uncomfortable is taking medication for a symptom I don’t yet have,” she said. “If it’s going to be preventative … I’d happily do it. But if we don’t have the data for that, why am I taking a medication for nothing?”
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Wendy Tuohy is a senior writer focusing on social issues and those impacting women and girls.Connect via X or email.From our partners
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