According to Statistics Canada, there are over 5.3 million people in British Columbia,[1] and nearly one-quarter of them are women 45 years of age or older. This prompts the question: for a condition that affects nearly 1.3 million people in our province, why aren’t we talking more about menopause?

When I teach UBC medical students about menopause, I emphasize that it is a physiological diagnosis. It is a normal process in the lives of people with ovaries, wherein egg supplies have been depleted, ovarian function declines, and estrogen production drops dramatically. I also emphasize, however, that physiologic does not mean painless. The symptoms that ensue in the absence of estrogen, such as hot flushes, mood changes, sleep disturbances, and genitourinary atrophy, can range from mildly troublesome for some women to totally debilitating for others.

In February 2023, the New York Times published an article titled “Women have been misled about menopause.”[2] The author, Susan Dominus, does an admirable job of summarizing women’s silent suffering as a result of our society’s reluctance to acknowledge and treat the symptoms of menopause. One of her sources, Dr Rachel Rubin, says it best: “Menopause has had the worst PR campaign in the history of the universe.”

Prior to 2002, hormone therapy was common. However, after the early termination of the Women’s Health Initiative hormone therapy trial in 2002 and 2004, fears about hormone therapy hit the press, and the demand for prescriptions dropped dramatically.[3-5] Of the risks described in the Women’s Health Initiative trial (still the largest randomized controlled trial to date on hormone therapy), the one that has garnered the most enduring public attention is breast cancer. More specifically, in the group of over 16 000 women that could be assigned to take conjugated estrogen and medroxyprogesterone acetate, those taking both hormones for longer than 5 years had a relative risk of 1.26 for developing breast cancer. As Dominus points out in her article, “[w]hat happened next was an exercise in poor communication that would have profound repercussions for decades to come.” When investigators declared that the trial was halted because invasive breast cancer increased by 26% in users of combined hormone therapy, it caught a lot of attention from patients and physicians alike. However, that relative risk statistic sounded much scarier than if one considered the absolute risk, which was eight additional breast cancers per 10 000 women years.[3,4]

I am part of an online group for Canadian woman physicians in which a colleague recently posted about struggling with perimenopause. Vasomotor symptoms and dyspareunia were seriously affecting her work and her relationship with her partner. She polled the group to see if she should consider hormone therapy, asking whether the group thought it was safe. I was pleasantly surprised to see that replies were unanimously in support of hormone therapy. This tells me that the right information is out there and many physicians know about it; maybe some even read the two BCMJ articles on managing menopause in the October 2022 issue (insert winking emoji). The ongoing challenge is counseling our patients. As the New York Times article points out, the data on menopausal hormone therapy are nuanced, and the risks versus benefits need to be individualized. Practitioners may struggle to find the time for a thorough discussion on menopausal symptoms, which can often involve addressing misinformation and talking through the data, or lack thereof, on various “natural” options that are heavily marketed to this population.

In 2019, Dr Timothy Rowe and I wrote a BCMJ editorial titled “New research on hormones and breast cancer: The headlines don’t convey what women really need to know.”[6] I must now happily eat my words and declare that the New York Times is, in fact, telling women what they need to know. I can only hope that a lot of women read it.
—Caitlin Dunne, MD

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This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License [10].

References

1.    Statistics Canada. Population estimates on July 1st, by age and sex. Accessed 28 February 2023. www150.statcan.gc.ca/t1/tbl1/en/cv.action?pid=1710000501 [11].

2.    Dominus S. Women have been misled about menopause. New York Times. 1 February 2023. Accessed 28 February 2023. www.nytimes.com/2023/02/01/magazine/menopause-hot-flashes-hormone-therapy.html [12].

3.    Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the Women’s Health Initiative randomized controlled trial. JAMA 2002;288:321-333.

4.    Anderson GL, Limacher M, Assaf AR, et al. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: The Women’s Health Initiative randomized controlled trial. JAMA 2004;291:1701-1712.

5.    Crawford SL, Crandall CJ, Derby CA, et al. Menopausal hormone therapy trends before versus after 2002: Impact of the Women’s Health Initiative study results. Menopause 2018;26:588-597.

6.    Dunne C, Rowe TC. New research on hormones and breast cancer: The headlines don’t convey what women need to know. BCMJ 2019;61:373-374.