The use of menopause replacement therapy has once again hit the headlines, with female doctors in public debate and many GPs left scratching their heads.
By Cathy O’leary
HRT and controversy have long been bedfellows, but debate over the use of treatment – now referred to as menopause hormone therapy – has intensified in Australia in recent months.
A public forum called ‘So Hot Right Now’, held at the Sydney Opera House in March, developed into something of a flashpoint over the science of MHT, which spilt over to Perth shortly after.
Organised by two Australian GPs, consultants and patient advocates, the Sydney event featured GP Dr Louise Newson who runs a high-profile menopause clinic in the UK.
She has faced criticism for her hormone prescribing practices which use high doses, but she insists they are safe and provide women with what they need and want.
A few days after her Sydney appearance, Dr Newson gave a series of talks to doctors and women in Perth, organised by Hera, a menopause and women’s health clinic.
She told her audiences that without MHT, many menopausal women were suffering debilitating symptoms like brain fog and faced increased risks from diseases linked to inflammation like cardiovascular disease, which she said “shouldn’t be happening in 2025”.
Both events have shone a spotlight on how debate about MHT has rapidly expanded and become emotionally charged, particularly around the dosage of hormones being prescribed by a new breed of female doctors.
Challenging the old guard
These doctors are openly challenging the status quo and claims menopause is being over-medicalised, arguing that this trivialises the valid experiences of women who are often at their wit’s end.
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The conversation has become more nuanced, with focus not just on symptom control but also the diseases influenced by low hormone levels, such as heart disease, diabetes, dementia, autoimmune disease and cancer.
Perth menopause specialist and women’s health GP Dr Sunita Chelvanayagam co-founded the Hera clinic – the first GP-led menopause clinic in WA – in 2023 with Dr Michelle Cotellessa.
She told Medical Forum they wanted Dr Newson to speak in Perth because perimenopause and menopause needed to be part of the conversation for women and no longer swept under the carpet as a taboo subject.
Dr Chelvanayagam says that while 20% of women sail through menopause relatively unscathed, 80% struggle, not just with hot flushes, but with palpitations, fatigue, wild mood swings and heavy periods. For some the symptoms were severe.
Oestrogen depletion at menopause could also contribute to rapid muscle and bone loss, cognitive decline, elevated cholesterol and poor glucose metabolism.
“A lot of women want to take control of their health and we’re living so much longer but many women are in that sandwich era of looking after children, looking after older parents and working full time, so life is very busy,” she said.
“We see a lot of women who feel a bit indulgent sitting down and telling their story, but they’ve never been able to do that with a GP because no one’s got the time.
“I think GPs want to first do no harm, and sometimes that means taking the path of least resistance based on what we know.”
She said menopausal women were clutching at anything that could help them, but often came in saying they did not know what they should do.
Unfair scrutiny
“I think HRT’s been under so much scrutiny in a way no other medicine has,” she added.
“We use many medications off label – we use them for things like epilepsy and nerve pain – there’s so much that we use off label because that’s medicine, and no one bats an eyelid.
“Hormones now are very body identical, and there’s a lot of nuances in the dose, yet that raises questions.”
Dr Chelvanayagam said women now spent many years in a menopausal state, far more than their ancestors.
“Some women don’t think it’s very natural to have HRT, but it’s not natural to be menopausal as long as we are,” she said.
“We are meant to be pregnant, breastfeeding, then menopausal, but we spend decades and decades doing a lot more than we should. That’s where replacing hormones comes in, particularly in terms of brain function.
“It’s not about reversing ageing or a cosmetic improvement, it’s about helping with the risk of heart disease, osteoporosis and potentially dementia.
“We’re the sum of all our genetic predispositions to other chronic illnesses, so it’s not just one thing.”
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But some women’s health experts remain worried about what they regard as excessive and potentially unsafe dosages of hormones prescribed by some of their peers.
Organisations like the Australasian Menopause Society say advice and treatments for menopause should be evidence-based and consensus-based.
Where there is some consensus in the medical profession is that the attention being given to this important area of women’s health is long overdue, so some debate is to be expected.
In the spotlight
Menopause has gone from forgotten cousin to political asset – the subject of a recent Senate inquiry and ensuing promises of funding by the major parties, including a new rebate for menopause health assessments from July this year.
Three new body identical hormone medications were also added to the Pharmaceutical Benefits Scheme earlier this year, the first additions in more than 20 years and saving some women almost $550 a year.
It is a far cry from decades past, when some women resorted to carrying around paper fans and hanging a wet cloth around their necks as they struggled with what was termed ‘the change of life’.
For those faced with severe menopausal symptoms, it was not so much a change of life as life-changing, as they were forced to endure debilitating hot flushes, night sweats and mood swings.
But just as the contraceptive pill revolutionised women’s control over their fertility, hormone replacement therapy came into its own, offering women the chance to get their life back on track.
That was upended in 2002 after a big US study, the Women’s Health Initiative, reported a link between the risk of breast cancer, venous thromboembolism and coronary heart disease in women taking oral oestrogen plus progestogen.
It scared off millions of women and their doctors around the world from using the therapy, leading to a dramatic reduction in prescribing.
While the risks were later re-assessed and largely discounted, the HRT hangover remained, only to be reignited last year by a series of articles in The Lancet suggesting that menopause was being over-medicalised and wrongly treated like a disease, resulting in some women getting unnecessary treatment.
There was strong backlash to The Lancet articles, including from Professor Bronwyn Stuckey, medical director at Keogh Institute for Medical Research, consultant physician at Sir Charles Gairdner Hospital’s Department of Endocrinology and Diabetes, and Clinical Professor at UWA’s School of Medicine.
She worries that women are missing out on treatment that could not only reduce severe symptoms but also help stave off chronic diseases.
Prof Stuckey told Medical Forum that despite advances in understanding of the risks and benefits of menopausal hormone therapy, outdated research continued to raise concerns for both patients and their clinicians.
“I don’t think my own position has changed much at all over the years. There’s no doubt that menopause is an oestrogen deficient state,” she said.
“You can’t argue that it’s not that, so what are critics talking about? There is good evidence that oestrogen has a lot of protective effects bone-wise and cardiovascular-wise.
“Let’s not forget quality of life. You prescribe hormone replacement therapy to a patient and they say, ‘oh my God I feel much better’ or ‘you saved my life’.
“I think that people who haven’t been through it, or people who’ve had an easy menopause, and men of course, don’t realise what a change in the oestrogen levels does to women – palpitations, hot flushes, not sleeping, vaginal dryness and sex hurting.
“And they’ve got to put up with that for the rest of their lives if you don’t do something.”
Prof Stuckey said what had changed since the WHI study was a real push to optimise which progestogen doctors used and the way they gave it.
“From the cardiovascular point of view that was known for quite a while, but the effect of the progesterone on breast cancer risk was a good take home message from the study.”
Prof Stuckey says persistent claims of over-medicalising menopause are nonsensical.
“When you think of the medicalisation of obstetric practices, the medicalisation of treatment of infectious disease, using antiseptics when you deliver a baby – these things have meant that women’s lifespan has increased past child-bearing age,” she said.
“Doctors have caused this, so with menopause they should also be responsible for things like osteoporosis and female cardiovascular disease – all of those things that come after menopause.”
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She also targeted men “with intact testes” who did not understand how horrendously some women suffered in menopause.
“If their testosterone dropped off, then they’d understand,” she said.
Prof Stuckey said she was deeply concerned about some of the long-term effects of low hormone levels.
“It’s not just symptomatic menopause, it’s things that happen like the bone loss,” she said.
“After the WHI study women started to avoid hormone replacement therapy for maintenance of bone density and so now we’re stuck with people in their early 50s who are on weapons grade anti-resorptive therapy like bisphosphonates, which are not so much of a problem, but Prolia (denosumab) is a big problem.
“If you put somebody who’s in their 50s on it, you know there’s no approved protocol for exit strategies with that.
“And then you get these rebound multiple vertebral fractures in people if they stop it.”
But Prof Stuckey is wary of some aspects of the new wave of enthusiasm for menopause treatment and some of the hormone doses being used.
“We have this push by people who seem to have discovered menopause after not having wanted to touch it with a barge pole,” she said.
“I agree some people need higher doses than others, but I think with the sort of doses Louise Newson uses you are going to run into the trouble of tachyphylaxis, where the higher the dose you give the more people are dependent on a high dose.
“For instance, the worst time for hot flushes is perimenopause when the oestrogen is swinging up to very high levels and then plummeting down to low levels, so that sort of fall in oestrogen triggers symptoms and if you keep chasing that you get into a bit of trouble with tachyphylaxis.
Making it personal
“Younger people definitely need higher doses than older people, but everybody’s different. With some people you can maintain their bone density and their quality of life on a smidgeon of oestrogen and some people you need to use high doses.
“Some people are happy with oral and some people you need to use transdermal.”
While the lack of consensus on MHT makes it difficult for GPs to decide how best to help their patients, a view now being embraced by many clinicians is that while MHT has a firm place in the treatment bag, the dose and delivery need be individualised rather than a one-size-fits-all.
It is an approach that Prof Stuckey supports.
“You definitely can’t have one therapeutic formula in your kit bag, you have to know what all the others do and what they don’t do,” she said.
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Dr Chelvanayagam also welcomes a personalised approach.
“I think it’s good for women to hear what is actually a good news story, that there is something they can do, no matter if it involves taking hormones or not,” she said.
“It’s not indulgent, it is a good thing to do something about your health.
“There are many different ways of going about it, but it’s really about optimising through a range of things including exercise, diet, social connection.
“It’s giving women quality of life when we’re so conditioned by society to just muddle on and keep going.
“I think it is the most transformational medicine we’ve ever come across as doctors and it’s not always easy, but when you talk to women and then see how well they do, that’s really amazing.”
ED: Additional resources can be found in the Practitioner Toolkit for Managing Menopause.
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