When menopause makes headline news, it's rarely a sign of something good. Menopause has become a multi-billion dollar industry. When something shakes the boat, big forces come into play. There are interests to protect, after all.
This post aims to shed light on what is true about women's health, and reveals how the interplay of medicine, media and myth have distorted menopause.
We'll start by looking at what happened in 2019, when we learned from research carried out at Oxford University that the risk of breast cancer from HRT was higher than previously thought.
The day this news story was picked up by the media, all hell broke loose.
Women taking HRT, understandably went into panic. Menopausal women who had chosen to avoid HRT were keen to share: “I told you so!” Pharmaceutical companies went into crisis mode. Doctors, who have spent decades promoting HRT, went on the attack telling women that if they don’t take HRT, they are more likely to get a chronic disease.
In the confusion, social media was full of women throwing insults and feeling insulted – testament to how far we are from understanding menopause, a natural part of our life cycle.
This HRT scare came just weeks after another story had many women drooling over the prospect that they could avoid the menopause altogether.
“How to delay the menopause” ran the headline in The Sunday Times.
“New medical procedure could delay menopause by 20 years” read the headline in The Guardian.
It was a UK-based ovarian tissue cryopreservation company that grabbed the attention of many when they proposed that women can put their biological clocks on hold by removing and storing ovarian tissue for future use. The company argued that this could allow a woman to delay the onset of menopause.
The company claimed that nine women between the ages of 22 to 36 had so far had some of their ovarian tissue removed and frozen. The women hoped that in the future, the tissue will be thawed and reimplanted in such a way that their depleted hormones could be reboosted and midlife menopausal symptoms avoided.
Although preservation of ovarian tissue has been used for over 15 years to protect the ovaries of girls and women undergoing cancer treatment, as Richard Anderson, the deputy director of the Centre for Reproductive Health at Edinburgh University, stated in The Guardian article, the safety and effectiveness of such a procedure for women who would otherwise be going through the menopause, remains unclear.
It’s unclear because we don’t have data on the possible side-effects that such a procedure could have on a woman, ten or twenty years after she would have the ovarian tissue reimplanted during her 40s or 50s.
Such uncertainty hasn’t prevented medicine moving ahead in the past. In the 1960s and 1970s, estrogen therapy was widely promoted as a “wonder pill” to ease a long list of symptoms commonly associated with menopause. Today, as the latest HRT scare demonstrates, we are still discovering the less desirable impact of menopausal hormone therapy.
Unfortunately, over the decades since the hormone therapy revolution took off, there have been many scares. Apparently large scale clinical trials were always an afterthought when it came to hormone-based menopause treatments, as they will be an afterthought regarding ovarian tissue preservation – women are already signing up for the procedure without knowing all the risks. No-one yet knows all the risks.
When the FDA first approved estrogen therapy for the treatment of menopausal symptoms back in 1942, there were well respected endocrinology and cancer researchers who were alarmed by the idea that healthy women were going to be increasingly treated with hormone therapies. They were concerned that since estrogen could act as a cancerogenic, the risks might outweigh any benefits offered to women going through natural menopause.[1] In 1938, these concerns led the Journal of the American Medical Association (JAMA) to publish an editorial, entitled “Estrogen Therapy—A Warning.”
That warning, and others, were ignored until in 1975, two important studies were published in the New England Journal of Medicine (NEJM). The studies concluded that among women who took menopausal estrogen, the risk of developing endometrial cancer (a cancer that arises from the lining of the uterus) was up to five times higher than normal rates, and 14 times higher than normal rates if women took estrogen for more than seven years.
By 1978, the FDA mandated that all estrogen products contain a warning message that estrogen had been proved effective only for hot flashes and vaginal dryness and that estrogen therapy carried risks of cancer and blood clots.
In 1980, a research paper published in The American Journal of Public Health estimated that in the US, more than 15,000 cases of endometrial cancer had been caused by replacement estrogens during the five-year period 1971-1975. This, argued the paper’s authors, created the largest epidemic of disease that had ever occurred in the US as a result of medical intervention.
But who could have known back when estrogen therapy was the latest “wonder pill?” Of course, that has been a question for the courts.
Instead of re-examining the wisdom of boosting women’s estrogen at a time when her body is naturally depleting it (not to mention perhaps, the unthinkable – appreciating the innate wisdom of women’s bodies) the pharmaceutical companies, which had already enjoyed tremendous revenues from hormone therapies, decided it was the woman’s body that didn’t know how to protect itself from additional estrogen, and this could be solved by adding progesterone to the mix. So progesterone was added to hormone therapies (to protect the uterus) and a combined therapy (which became known as HRT) was offered to women instead.
In order to overcome “all that bad press” that estrogen increased the risk of cancer, the makers of HRT switched the tone of their marketing to promote the idea that HRT not only offered relief for menopause symptoms but also reduced the risk of osteoporosis and heart disease.
So were these claims true?
In 1986, the FDA deemed estrogens “effective therapy” for osteoporosis, but that is quite different from saying that estrogen should be administered to women at midlife to reduce a future risk of osteoporosis.
The research that led to the “effective therapy” declaration only included women who had entered artificial menopause through the surgical removal of their ovaries, not women who went through menopause naturally. Surgical menopause brings about more abrupt and greater bone density loss, which can be reversed through estrogen replacement. But assuming that ovary removal and natural menopause is one and the same is a mistake – and a dangerous one too.
Charles Dodds, who first published the formula to create synthetic estrogen in 1938, had throughout his career recommended caution in administering hormone therapies to women passing through a natural menopause. He recognized the disruptive power of such therapies and was aware that hormones “could alter the metabolism in every cell and organ of the body.” Dodds knew that estrogen stimulates growth, in bone cells and cancer cells, and that there is a relationship between estrogen and bone density which was (and still is) widely ignored: women and other mammals get more female cancers when their bone density is relatively high, and less when it’s relatively low. Since death from cancer would normally occur earlier than death from a hip fracture, the logic of administering estrogen to healthy women journeying through menopause to prevent a possible future case of osteoporosis must be questioned. [1]
Back in the 1980s, estrogen was often administered over decades. This meant that if the bone density of a 70 year old woman taking HRT was compared to that of a 70 year old woman who had not taken HRT, a difference in the bone density could be expected. Today HRT is not given for such long periods and doctors know that when a woman stops HRT (these days, usually in her 50s), there is no long term culminative effect with regards to bone density. Since most women are only at risk from osteoporosis decades after they reach the menopause, unless a woman already has osteoporosis at midlife, no hormone therapy given to menopausal women can be expected to impact bone density later on.
More than this, we must also question if a fixation on bone density is even helpful. In another stunning rejection of the notion that the body might just have a plan of how best to age, tried and tested by evolution, since late last century, all norms of female bone density have been based on the average bone density of a 30 year old woman, as if the body is designed to remain 30 forever!
What a body needs at 60, 70 and 80 is not what a body needs at 30, and yet a whole industry has developed around bone density testing, medicines and supplements, which are founded on a notion that at every age we need to have the bone density close to that of a 30 year old. In fact, what we need are strong bones which does not necessarily equal dense bones. Strong bones behave more like wood when faced with a fall, as opposed to dense bones, which as we age would behave more like glass. Glass is more dense than wood but in a fall, more likely to shatter.
Further reading on the misunderstandings surrounding osteoporosis and osteopenia, can be found in this fascinating article. But for now, let’s return to the second claim that medicine made popular in the 1980s and ask the question: does estrogen therapy lower the risk of heart disease?
The science behind the idea that HRT could reduce the risk of heart disease was always the equivalent of medical hearsay – relying on the results of small scale trials. The FDA never approved using HRT for this purpose. But it wasn’t until the 1990s, that the industry even got around to commencing the first large-scale clinical trials specifically designed to evaluate the effect of hormone therapy on coronary heart disease (CHD) and women’s long-term health. Then, both the Heart and Estrogen/Progestin Replacement Study (HERS), which was published in 1998, and the Women’s Health Initiative (WHI), concluded that HRT did not prevent heart disease. More than that, the Women’s Health Initiative was abruptly halted in 2002 because early findings revealed that post-menopausal women taking estrogen and progesterone combined hormone therapy had an increased risk of heart disease, breast cancer, stroke, blood clots, and urinary incontinence.
HRT sales went into free fall and it was time for some crisis management and new messaging. Once the dust settled, the makers of HRT were back with a new spin: we don’t need to worry about the results of WHI because the research was “misguided.”
The pharmaceutical industry argued that we should discount the results of WHI because the study included the impact of HRT on women who were 10 years and more beyond menopause – as if doctors hadn’t just spent decades prescribing HRT to women who were 10 years and more beyond menopause, and that’s why those women were included in the study.
None of what was found to be dangerous for the older postmenopausal women was necessarily relevant to women at midlife, the industry concluded. And with that argument, doctors returned to convincing menopausal women that taking HRT could prevent heart disease, dementia and even cancer, even though an estimated 200,000 women were diagnosed with breast cancer as a result of taking combined HRT and to date, 10,000 women have won claims of nearly $1 billion after developing breast cancer linked to a single HRT drug.
You see, the problem is that when society has been telling us for millenia that women in their natural state are more prone to malfunction, it’s hard to drop those ideas and it’s even harder to see that women’s bodies naturally operate in a way that best preserves women’s health through menopause and beyond.
However, 2017 would prove to be a turning point.
In that year, The Journal of The American Medical Association (JAMA) published the findings of an 18-year clinical trial, which investigated the safety of hormone therapies. The trial compared the mortality rates of women who took hormone replacement therapy for a median of six to seven years with women who received a placebo. The research found that women who received hormone therapy were no more or less likely to die of any cause than the women who received a placebo. This led the study’s authors to conclude that they “would not support the use of hormone therapy for reducing chronic disease or mortality.”
The trial’s findings jolted the North American Menopause Society (NAMS) to update their policy statement on HRT. In addition, doctors who had enthusiastically shared how HRT could protect women from disease had to finally stop sharing those made-up stories!
At least, doctors on one side of the pond.
Since NAMS updated their policy statement, I have noticed that doctors in the US who were at the forefront of sharing the myth that HRT prevents disease, have changed their story (and updated their websites). But not so in the UK! Even though menopause societies from countries around the world endorsed the NAMS 2017 position statement, the British Menopause Society stood alone in just “supporting” it.
With Britain running behind in the “drop-the-menopause-myth” trend, perhaps it’s no surprise that when a panel of women was gathered on BBC Radio 4’s Woman’s Hour to discuss the possible pros and cons of delaying the menopause through ovarian tissue preservation, every member of the panel contributed her own myths to the discussion, and nobody was on hand to challenge them.
Emma Hartley, who penned the headlining article in the Sunday Times that lead to the explosion of “delay your menopause” fever, claimed: “These new technologies are actually the second bookend to the product that was started in the 1960s [which allowed] women domination over their own biology, in a way, to avoid the tyranny of it.”
Oh dear.
Hartley also complained how even before she’s reached the menopause, she has arthritis.
I’m sorry for Ms Hartley that she’s experiencing arthritis, yet blaming it on perimenopause is misguided. Even the UK’s NICE guidelines on menopause (which appear less up-to-date than those from North America) make no mention of arthritis.
Dr Melanie Davis was the medical voice on the Woman’s Hour panel. Having given a nod to common-sense good lifestyle to maintain our health, Dr Davis bemoaned how a loss of estrogen leads to bone-thinning (which is misleading, as I explained above) and an increased risk of cardiovascular disease (which has only ever been disproven in large scale clinical trials).
Allison Pearson, author of the book, “How Hard Can It Be?” and a columnist for The Telegraph, expressed her concern over the invasiveness of ovarian tissue preservation and questioned why we would want to postpone menopause, since with menopause comes freedom, strength and wisdom. She also shared her satisfaction with taking non-invasive combined HRT – “fantastic” she called it.
I’m happy for Ms Pearson that HRT has brought her symptom relief. Hopefully she is riding out the latest HRT scare by looking at the facts and figures and connecting to what still feels right for her. But I’m not sure how to break it to Ms Pearson and other women who have chosen a similar route: HRT also postpones menopause.
In the past, this was less obvious because menopausal women were often prescribed HRT for decades. These days, many women are discovering that when their seven years of HRT are up, their menopause symptoms return, with a vengeance.
As the discussion evolved on Woman’s Hour, the show’s host, Jenni Murray, alluded to another popular menopause myth by asking: “What about the fact that because we are now living longer, there is a real fear that women’s bodies were not designed, if you like, for decades after our procreative powers evaporated, and we are up against it, unless we protect ourselves with, for example, HRT?”
Perhaps predictably, Dr Davis failed to point out in her answer to this question that women have always lived beyond menopause (as I’ve explained in detail in this myth busting post).
During the discussion on Woman’s Hour, Pearson did ask thoughtfully, “What are we doing tampering with the natural female cycle, the female body, for the convenience of society? …Work and society should be adjusting itself to the female biology, not the other way around.”
(Although again, HRT is tampering with the natural female cycle.)
Suzanne Moore, writing in The Guardian, argued a similar point:
“It’s not women’s menopausal bodies that need ‘fixing’ but society’s attitude to them….Instead of expensive and invasive operations, how about we support women for a change?”
Yes, and yes! But in order to support women we need to radically transform our understanding of menopause…and our life-cycles.
Since time immemorial, women have been defined and reduced to the workings of their ovaries, right from the beginning of their reproductive years.
At their first bleed, girls have been married off and fast-tracked to motherhood. Child brides were and still are given no time to journey into womanhood, discover their spirit and respect the wisdom of their body, which requires years to settle into fertility in order to create optimum conditions for a birthing mother and her baby.
Today we know for a fact that the younger the birthing mother, the higher the incidences of birth complications and abnormalities, maternal and infant death. By setting minimum marriage ages at 18, we brought the focus away from the ovaries of adolescent girls, and restored respect to the female body, whether intentionally or not.
Looking toward the end of our reproductive cycles, even before hormones were understood and estrogen isolated, one of the first Western medical interventions during the menopausal years involved feeding or injecting women with animal ovaries. Ovarian therapy may have become estrogen therapy and then HRT, but the underlying obsession with our “faulty” ovaries remains at the heart of medical approaches to menopause, whether it be HRT or ovarian tissue preservation.
There is no room to appreciate the innate wisdom of a woman’s body when the changing role of a woman’s ovaries, the depletion of her pool of eggs and fluctuating levels of hormones are considered faulty and something to overcome.
But what if we drop the obsession with our ovaries? What if we see that for a woman journeying through natural menopause, supplementary hormones or implanted ovarian tissue can’t make sense?
What if we understand that at the heart of menopause is a woman’s transformation – the realignment of energies, the bubbling to the surface of wisdom and the progression into her wiser woman role?
What if we saw that for this transformation to occur, her ovaries and her hormones must change as nature intended?
Instead of trying to understand a woman as a sum of her parts (parts that at a certain age will need to be fixed, or manipulated or cut up, frozen and reimplanted), it is time that we understood that WOMAN is so much more than that!
WOMAN is a whole magnificent ecosystem, designed to preserve our innate health. It is an ecosystem that must transform at midlife. Understanding the divine nature of this transformation is essential if we want to journey through change with fewer symptoms and more joy.
This is what’s on offer for every woman once we see beyond the myths of menopause.
[1] Barbara Seaman, “The Greatest Experiment Ever Performed on Women” (2003)