In 2002, a well-intentioned but flawed study forever changed medical care for middle-aged women. It suggested that hormone therapy, which at the time was the gold standard for treating menopausal symptoms, increased the risk of breast cancer, heart attack, and stroke.
The results were immediate and shocking. In 2001, doctors issued him 112 million prescriptions for hormone therapy in the United States. This only decreased by almost half to her 61 million two years later. By 2008, the number of prescriptions had fallen by more than 70% to less than 32 million in just seven years.
A wealth of research has since debunked these initial findings. But the damage was done. For a long time, medical schools have taught that hormone therapy does more harm than good. Even as the evidence changed and major medical societies changed their guidelines, many doctors stopped prescribing it.
The mistaken belief that hormone therapy should be avoided has led to a large treatment gap in menopause care. One study found that only 4% of women over 50 were receiving hormone therapy in 2018 and 2019, down from more than 22% in 1999 and 2000.
I was in my second year of medical school when news broke about that flawed study conducted by the Women's Health Initiative (WHI). I remember that the results were so negative that the National Institutes of Health, which funded the study, decided to end the study three years early. Participants assigned to receive hormones were told to stop because it was too dangerous.
Until I started researching this series on menopause, I thought that was the end of the story. Indeed, dozens of subsequent papers, including one written by WHI investigators, have shown that the initial results were seriously misinterpreted.
Many of the errors stem from the assumption that WHI students investigated the safety and effectiveness of hormone therapy for menopausal women. It didn't. As two of the WHI researchers wrote in a 2016 New England Journal of Medicine article, the goal of the study was to use hormone therapy to prevent long-term chronic diseases in postmenopausal women. The purpose was to consider whether it could be used. The average age of menopausal women in the United States is 51 years old. In the WHI study, the average age of the participants was her 63 years.
The correct conclusion of the original study should have been that the risks of hormone therapy outweigh its benefits when used in postmenopausal women to prevent chronic disease. However, in 2002 it was reported that young women should not take hormones, even though they are the most effective treatment for menopausal symptoms such as hot flashes, night sweats, painful intercourse, and urinary incontinence. It was said that there was no such thing. In young women, the hormone also had the added benefit of reducing bone loss and improving heart health.
Follow this authorLeana S. Wen's opinion
Earlier this month, WHI researchers published an updated analysis of their results. The bottom line is that hormone therapy is appropriate for managing menopausal symptoms when started before age 60, the study's lead researcher and Harvard Medical School professor Joan E. Manson said in an interview. is. “It should not be used as a reason to deny hormone therapy to these women,” she said.
Manson was quick to clarify that women who are not experiencing menopausal symptoms should not use hormone therapy to prevent chronic disease. That's because the bar is set much higher when used solely for prevention rather than treatment.
In addition, the WHI findings show that starting oral hormone therapy many years after a woman's last period significantly increases the risk. But older women aren't without options, Munson said. For example, low doses of vaginal estrogen can reduce symptoms such as vaginal dryness and discomfort during sex. This is because such parenteral therapies are not as well absorbed through the bloodstream and are therefore less risky.
There are also women who should not receive hormone therapy, such as those with estrogen-sensitive cancers, blood clots, or a history of heart attacks. Others may personally prefer some antidepressants or non-hormonal treatments such as fezolinetan, which was approved in 2023 to treat hot flashes.
“It's important that clinicians are able to fully discuss these options with patients,” Munson says. But she recognizes that many patients are unable to find a clinician with whom they can even discuss treatment possibilities. She feels the problem is that doctors continue to lack training to manage this condition, which 100% of her middle-aged women experience.
This has to change. Clinicians and patients should learn how misinterpreted research led to substandard care for millions of women. We need to spread the word that hormone therapy for menopausal women does not deserve its bad reputation. That was never the case.
Thank you to the readers who sent in questions. We covered some of them in last week's The Checkup newsletter. I will answer this question in more detail in a future article. We would love to hear your thoughts. Next, what topics should we cover about menopause and perimenopause?
