Why HRT has a bad reputation: the story of 2002

In 2002, two studies (one American, one British) sent shockwaves through the press: one showed an increased vascular risk in women on HRT, the other a breast cancer risk multiplied by 1.6. These studies instilled lasting fear, but were quickly criticized by French scientists.

The flaws in these studies, explained

First flaw: the hormones used in these American and British studies had nothing to do with what's prescribed in France, where bio-identical hormones are used (identical to those naturally produced by the ovaries), only recently recognized in the United States. Second flaw: the American study included women averaging 62 years old, who already had vascular risk factors. We now know that the earlier HRT is started, the lower the risk and the greater the benefits.

Early menopause, a special case

True early menopause is before age 40 (before 45 is already considered too early). For these women, going without estrogen for 10 to 15 years before the normal age of menopause represents a major risk to blood vessels and bones. Treatment isn't even up for debate: Odile compares it to not giving insulin to a diabetic woman. Diagnosis must be confirmed with a hormone panel (to rule out other causes of missed periods, like a prolactin-secreting tumor), and once confirmed, treatment is necessary.

Benefits for climacteric symptoms

HRT eliminates hot flashes, genitourinary syndrome (including vaginal dryness), improves sleep, improves mood issues linked to menopause (not those with another origin), and eliminates joint pain when it was the main symptom.

Benefits for bones and the cardiovascular system

Cardiovascular: more flexible blood vessels, fewer atheroma plaques, so fewer heart attacks and strokes. Bone: slower bone loss and osteoporosis prevention. HRT is even officially recognized as an osteoporosis treatment, alongside bisphosphonates or raloxifene, with an added preventive effect.

How HRT works: two hormones, not one

HRT always combines two hormones. Estrogen makes up for the deficiency and treats symptoms, but given alone, it thickens the endometrium (the tissue lining the uterus), with a risk of endometrial cancer. Progesterone counteracts this effect by protecting the endometrium.

The real story on breast cancer risk

Breast cancer risk only increases if the progestin component of the treatment isn't bio-identical progesterone: with another progestin from the same family, the risk goes up. With bio-identical progesterone, there's no increased breast cancer risk in the first 5 years, a well-established fact.

Vascular risk depends on the route of administration

Vascular risk doesn't increase if the estrogen is bio-identical and given transdermally (gel or patch), rather than as a pill. In pill form, the hormone passes through the liver and disrupts clotting factors, increasing the risk. Transdermally, not only does the risk not increase, but blood vessels become more flexible, which decreases vascular risk.

An underrated benefit: protection against certain digestive cancers

HRT lowers the risk of several digestive cancers: stomach, liver, pancreas, and especially colon cancer (like the birth control pill, which has the same effect). Colon cancer accounts for about 20,000 cases a year in France. The only risk that slightly increases with HRT is ovarian cancer (about 5,000 cases a year), a trade-off Odile considers strongly in favor of HRT.

HRT isn't mandatory: it's a matter of choice

There's no obligation to be treated: a woman with no particular vascular or bone risk, and no bothersome symptoms, can choose not to take HRT. She won't escape vaginal dryness, though, which affects all women over time (regular sexual activity helps limit it). The French National College of Gynecologists and Obstetricians (CNGOF) published a major literature review at the end of 2021 confirming that benefits outweigh risks for most women.

Contraindications and misconceptions to correct

The main contraindication is a personal history of breast cancer, not a family history.

Many women wrongly think their mother's breast cancer bars them from HRT. That's not true, even though some doctors keep the confusion alive by asking the question in a leading way. Another common source of confusion: the fact that HRT is stopped when breast cancer is discovered makes some women believe the treatment caused it, that's not the case, and cancers discovered while on HRT actually tend to have a better prognosis.

Choosing the right gynecologist for menopause

Not all gynecologists are equally interested in menopause: some are more drawn to surgery or pregnancy follow-up. It's perfectly fine to switch gynecologists for menopause care if your current one isn't a good fit. A parliamentary report (the Riste report) has led to better training for gynecologists and general practitioners on the topic in recent years.

Alternatives, who they're for and why

Alternatives are primarily for women who have no choice (history of breast cancer), and those who, for personal reasons, prefer not to take HRT, a choice that should never be guilt-tripped, unlike what some shaming online discourse might suggest. These alternatives (dietary supplements, psychological support, physical rehab for urinary or sexual issues) mainly target libido and mood issues when they're not directly linked to menopause.

"Integrative menopause"

Odile extends the concept of integrative health covered earlier in the series: HRT (or not), dietary supplements, a fulfilling sex life, and a rich social life are all part of a comprehensive, personalized approach to menopause.

See menopause as an opportunity and be kind to yourself. Take a bit of time for you, and let everyone else figure themselves out.