Are you ‘missing out’ if you’re not on HRT/MHT?

Is not taking hormones dooming you to poor health outcome?

At talks I’ve done recently, I’ve had a couple of questions in a similar vein. That theme is:  if I’m not on HRT, am I missing out on something? Do I have to be on it to be my healthiest self?

I can see where these questions come from. If you, like me, are immersed in Menopause Instagram (and probably Facebook too; I’m not active there so I’m guessing) you will have seen many, many posts from people - some of them doctors - promoting the benefits of HRT. Some of these seem to be suggesting that HRT is a miracle, health-promoting, preventative and essential medication for women in perimenopause and beyond, and that if you are not on it, you are somehow missing out on some incredible benefits both now and down the road. This extends not only to standard HRT (oestrogen and progesterone) but also testosterone. I’ll tackle testosterone in a separate piece, but for now, here’s what you need to know about claims like these around oestrogen and/or progesterone.

First, don’t worry

If you are not on HRT, because you can’t be, or you don’t want to be - do not stress. You are not doomed to age faster than your hormone-patched friends, or to an old age of poor health. Here’s some reassurance for you.

HRT is great - but it’s not magic

I am a user of HRT, and so I know that it can be really good for those of us who are struggling with symptoms of perimenopause and menopause - especially those biggies like hot flushes, night sweats, mood issues, cognitive issues and sleep problems.

But HRT is not a magic pill. It’s not the one thing that’s going to magically sort out all the midlife health issues and make you feel amazing, all on its own. It is just one part of a the puzzle when it comes to both sorting out menopause symptoms, and looking after our health long term. I’ve written two whole books about all those pieces - and they include HRT along with all the stuff we know about but don’t always find it easy to focus on: food, movement, stress management, sleep, hydration, alcohol use, relationships, self image and self care in many different forms, along with lots of other stuff.

I know we all love the idea of a magic pill, supplement or potion. But it’s really not reasonable to expect one thing to solve a complex situation like menopause - especially if we don’t have all those other pieces of the puzzle in place. As we’ve heard before: HRT is NOT lifestyle replacement therapy. It won’t help all that much if you don’t have the basics of health in place. In other words: no pill or patch or gel is going to make you feel amazing if you’re still stressed out; staying up late scrolling the socials; drinking alcohol regularly; not moving your body and not nourishing yourself with good food.

It follows that if you are not on HRT, you can still look after yourself both now and in the future by working on all those other basic things. You are not doomed!

What about HRT for prevention of disease?

We know HRT does have some protective benefits for health. But I think it’s worth noting here that - despite those posts suggesting otherwise - none of the world menopause bodies recommends starting HRT for the prevention of diseases in its official guidelines. That includes the British Menopause Society; the American Menopause Society (they’ve just re-named themselves ‘The Menopause Society’ because you know, America is the whole world); the International Menopause Society and our own Australasian Menopause Society.

And for the record, none of those organisations recommends HRT for youth-preserving measures, like keeping skin supple or preventing weight loss. I’ve heard women talk about these reasons for starting HRT; you should know there’s very little evidence for these benefits and that a doctor who would start you on HRT just for that is someone I’d be really wary of.

There is evidence that HRT is pretty useful for bone health, and that’s where there is a bit of nuance here. For example, the Australasian Menopause Society says that HRT reduces the risk of postmenopausal bone fracture, including hip fracture. For women who have early menopause, or surgical menopause before 45, HRT is recommended for that reason until at least the natural age of menopause. And sometimes when women are at high risk of fracture, this is a factor in the decision to start on HRT.

There’s also evidence HRT is protective of the heart, but again, it’s not recommended to take HRT just for that reason.

The jury is out on whether HRT is helpful for the brain, eg for preventing dementia. Studies have shown both benefit and increased risk on this - so we need more information to know for sure. Again, it’s not a reason to start HRT on its own. And in all of these things, at the risk of being a broken record: there are lots of other things we can do to help with them that are not HRT.

What are good reasons for starting HRT?

The decision to start HRT is individual - because every person’s experience of menopause is individual. What should affect your decision is a careful discussion with your doctor about your individual situation and symptoms, and your individual risks versus benefits.

Don’t let your friends’ experiences affect your decision. This is not a time when peer pressure should come into the picture. Just because others are raving about HRT, doesn’t mean you have to go on it, too.

That said, HRT is absolutely worth investigating if you’re struggling with symptoms you think are perimenopause or menopause related. It should be a valid option offered to you in that situation; don’t let your doctor tell you your symptoms are not real or are ‘just part of being a woman’. A trial of HRT is a reasonable thing to ask for after you’ve had that discussion.

But also: don’t think you’re missing out if you’re not taking hormones. The idea that we’re all in some sort of deficiency state or are in a terrible decline if we’re not on HRT strikes me as another form of gendered ageism. (We don’t call pre-pubescent girls deficient in oestrogen, do we?). It’s also not supported by the body of evidence right now.

Recent work

ICYMI: I was asked to write this piece off the back of an Instagram post on the same theme. It’s an extension of the ideas in my book. Please read it if you’ve ever felt like your body wasn’t ‘right’.

https://www.rnz.co.nz/news/national/523058/the-messages-genx-women-need-to-hear-about-their-bodies