Jerilynn C. Prior BA, MD, FRCPC, Professor Emerita, Endocrinology/Medicine University of British Columbia
Recently a colleague of mine asked what I thought of a 2025 paper by Drs. Sarah Glynne and Louise Newson from the United Kingdom that was recently published in the journal Menopause. I read it as a women’s health researcher and as a woman who has been menopausal for over 20 years.
The publication says it is about Menopausal Hormone Therapy (MHT) for alleviation of “menopausal symptoms.” Next, however, it quotes an expert, a man, describing in the 1990s what estrogen levels he thinks prevent bone loss and ‘make premenopausal women feel good’. This paper then proceeds to share the hormone levels of those attending this private clinic who were treated with oral or transdermal estrogen (estradiol) and sometimes also with low dose oral micronized progesterone.
At first, I was confused. I thought this article was about treating menopausal night sweats and hot flushes. If so, we should have seen individual women’s baseline experiences of night sweat frequency and intensity, the frequency and intensity of their daytime hot flushes and how they were sleeping. We should have learned how these variables changed as each individual woman+ (of all genders) used a particular set of doses for three months.
Instead, what I was seeing was estrogen measurements. A lab test does not tell us what women experience. Where were women’s experiences, how they felt, what got better and what got worse? These are things only a woman can know.
I was also, and this worried me, sensing a notion that has long been scientifically and clearly proven wrong—that menopause needs treatment.
We, as women+ (of all genders), our culture and community, including many of our healthcare providers, are still confused. They are STILLacting as if menopause were a disease, an illness, something that requires treatment. Instead, the only kind of menopause that needs treatment is a kind that comes too early, or if menopause is causing problematic night sweats, severe hot flushes or persistent sleep problems.
Menopause, itself, is normal. Every woman+ living that long will become unable to bear a child. She will also eventually stop having menstrual cycles. With menopause, women+ enter a new, interesting and normal phase that lasts for the rest of our lives.
UK women went to a private clinic (that the reported study above describes) because they thought they needed estrogen to stay young-looking and healthy. They wanted estrogen in MHT. And they got it, often in very high and unsafe doses that led UK medical authorities to censor the clinic’s owner and physician. Women+ got MHT for menopause itself—a problem that does not exist (except within our persistently, man-focused culture).
The only scientific reasons for menopausal hormone therapy(MHT) are:
1. Menopause that came too early (one year without flow before age 40, and perhaps before age 45). Early menopause certainly needs transdermal estradiol (the natural hormone, through the skin as a patch or gel) and oral micronized progesterone (the natural hormone that comes as little round beige balls swallowed at bedtime). These women need both estradiol and progesterone as MHT because it will decrease their higher risks for heart attacks and fracture that arise simply because they had too short a menstruating life span.
MHT for early menopause should be continued until the usual age at menopause for that person’s population (about age 52 for White western women, but earlier for some peoples).
Stopping estrogen, however, may be problematic—see this information if night sweats/hot flushes/sleep problems get worse when you try to stop. The key is that estradiol needs to be stopped very gradually and with the support of continued progesterone in a dose of 300 mg every night at bedtime.
2. Symptomatic menopause needs treatment. Why? Because, untreated, it is associated with both heart attacks and hip fractures. By “symptomatic menopause” I mean night sweats disturbing sleep two or more times a week, daytime hot flushes severe enough to cause distress/dehydration or problematic mid-sleep awakenings leading to fatigue or depression. These can be treated with either MHT or with oral micronized progesterone alone (300 mg at bedtime daily). Progesterone is safer than estradiol because it is without estrogen’s risks for blood clots, and worsened migraines as well as trouble stopping suddenly. Progesterone does not cause a rebound increase in night sweats and other symptoms when it is stopped.
When you are having no night sweats or hot flushes for a year, just stop the progesterone. You will shortly learn whether or not you still need it. I did that for seven years before I could finally stop the progesterone I needed for night sweats and sleep problems.
What about the new FDA menopause pronouncements?
The USA political leaders regulating medications have removed the warnings (“black boxes”) about two things: vaginal estrogen for vaginal dryness or recurrent urinary tract infections; menopausal estrogen and progestin therapy. These warnings were instituted following the large Women’s Health Initiative randomized controlled hormone trials.
Removal of vaginal estrogen warning is excellent. Evidence says vaginal estrogen is safe, and that it is effective.
However, it is not to be used as a lubricant for sex. Instead, for vaginal dryness, always use one of the widely available non-hormonal products you can find at any pharmacy. Vaginal estrogen can be safely and effectively used if lubricants are not sufficient for discomfort-free sex or you have problems with your urinary system.
Removal of warnings about systemic, oral estrogen and synthetic progestins for menopause, are unwise and not supported by scientific data. The language in the recent FDA conference also implies that menopause, itself, causes all sorts of health problems. That is not true. We, all humans, men as well as women, experience changes as we age. They are usually caused by some complex combination of chronological ageing, genetics, lifestyle, social support and for women, premenopausal hormonal exposures, especially rarely detected or treated subclinical ovulatory disturbances.
Menopause cannot be separated from ageing. Menopause itself does not cause osteoporosis, heart attacks and dementia. The accurate, scientific news is that MHT, even with the most evidence-supported transdermal estradiol and oral micronized progesterone, does not prevent the cardiovascular changes associated with ageing.
Remember—it remains important and necessary to ask for MHT or oral micronized progesterone if you are having a symptomatic menopause. Otherwise, enjoy the privileges of ageing (lower transit and concert costs and that your grandkids go home to their parents after a delightful but sometimes demanding visit).