Hormone-based medications for early menopause: Health Practitioners’ perspectives

Hormone-based medications for early menopause (EM) include oestrogen-based therapies
Hormone Replacement Therapy (also known as Menopause Hormone Therapy), hormonal contraception, and testosterone (androgen) therapy. Oestrogen based therapies suit women in different circumstances and can help alleviate the symptoms of EM (see Symptoms of early menopause), including hot flushes, night sweats and vaginal dryness. Oestrogen-based therapies may help reduce the risk of osteoporosis and heart disease (see Long-term health effects of early menopause). Testosterone (androgen) therapy may be used to help manage sexual function problems. In this Talking Point, we will refer to Hormone Replacement Therapy and hormonal contraception as ‘HRT’ unless otherwise stated.

Women with EM who are able to take HRT are advised to do so until at least age 50-51 years (approximate age of natural menopause), unless they have experienced hormone sensitive cancer (see Non-hormone based medications for early menopause symptoms after oestrogen-sensitive cancers).

The health practitioners we interviewed shared their experience of discussing HRT with women diagnosed with EM. The importance of offering HRT and informing women of its benefits, in particular its protective effect on bone mineral density, was emphasised by health practitioners.

General practitioner Dr Goeltom explained the benefits of hormone-based medications and lifestyle changes for women experiencing EM and recommended a ‘holistic’ approach to care.

Dr D, an endocrinologist, discussed the different hormone therapies she offers women, depending on their health and other circumstances.

The Women’s Health Initiative

Several health practitioners expressed their concern regarding the findings of the 2002 Women’s Health Initiative (WHI) study and its consequences for HRT use (for an explanation of WHI and other HRT studies, see this link ). Endocrinologist Dr D noted that the study had implications for both women and some health practitioners: ‘hormone therapy was in very widespread use in Australia pre 2002 … and when [the WHI] study … findings were announced hormone therapy use dropped dramatically because there was a lot of fear about it. The fear was not only at the ladies’ ends, but was also at the general practitioner end.’ Dr W, an endocrinologist, added: ‘the fear around menopause and use of HRT in older women has translated into a sort of lack of knowledge [in] younger women as well, I think.’ (See Hormone-based medications for early menopause: Women’s knowledge and perspectives.)

Obstetrician-gynaecologist Dr Baber reflected on the findings of 2002 Women’s Health Initiative study.

Decision-making

The importance of giving women clear information on the risk and benefits of HRT and respecting their decisions was emphasised by health practitioners.

For general practitioner Dr Ee, health practitioners need to spend time explaining treatment options, including HRT, to women.

In obstetrician-gynaecologist Dr Baber’s experience, decisions on HRT need to be made ‘in consultation’ with women.

Side effects of HRT

Health practitioners acknowledged that some women may experience side effects when taking HRT and that this needs to be discussed with women. Obstetrician-gynaecologist Dr C said: ‘If you start people who have had no oestrogen in their system straight on higher doses of oestrogen, they’ll just vomit. You start low, low, low. They get breast tenderness too … You just gradually increase it. Some people don’t ever tolerate a lot.’

Dr W, an endocrinologist, explained that the side effects of HRT can include ‘headache, nausea, [and] breakthrough bleeding.’ She also noted that while the evidence on HRT and weight gain is inconclusive, some women ‘get very increased appetite on some of the hormones [and] get fluid retention…’

Dr C, an obstetrician-gynaecologist, discussed how it can take time to find the right dose of HRT, and explained that some women can find it difficult to distinguish between the side effects from HRT and their EM symptoms. 

Endocrinologist Dr D shared her experience of caring for women who experience side effects when taking HRT. 

Bioidentical compounded hormones

The use of bioidentical compounded hormones by women was discussed by a few health practitioners. They observed that there is inconclusive evidence on the effectiveness and safety of bioidentical compounded hormones, which makes discussing their use challenging for health practitioners. “Bioidentical” refers to hormones that are the same as the body naturally produces and these are now available as part of conventional HRT. Specialist medical societies relevant to menopause and the USA Federal Drug Agency do not recommend the use of bioidentical compounded hormone therapy.

Dr W, an endocrinologist, explained that she does not generally recommend women taking bioidentical compounded hormones.

Breast cancer and HRT

The risk of developing breast cancer while taking HRT was discussed by several health practitioners. For Dr Stern, a fertility specialist, there are significant benefits outweighing potential risks to taking HRT, in particular for the protection of bone mineral density. She said: ‘while everyone’s anxious about the risks of breast cancer … there seems to be reasonable evidence that [women diagnosed with POI or EM] should seriously consider [taking HRT] at least in the short term.’

However, health practitioners emphasised that women needed to be well informed of the potential risks and supported to make decisions about whether to take HRT. As general practitioner Dr Ee explained: ‘women have come to me and said … “My mother or my sister died of breast cancer.” They’re not going to go anywhere near a hormone and I think as long as they have the information to make a decision and that I’ve listened to them and they’ve listened to what I’ve had to say as a health professional and we respect … each other, it really is up to the woman…’

For Dr D, an endocrinologist, it is important to offer women a ‘detailed’ explanation on HRT and the risk of breast cancer.

General practitioner Dr Barker shared how he discusses HRT and the risk of breast cancer with women, and explained that a different approach to HRT is needed depending on the cause of EM. 

Discontinuing HRT

Women with EM who can take HRT are typically advised to continue taking it until the usual age of menopause. When women on HRT reach 50 years of age, health practitioners explained that they evaluate women’s EM symptoms, in particular their bone mineral density and cardiovascular health. Dr W, an endocrinologist, said: ‘you reassess … we’d have a discussion about what they want to do. Whether they want to try coming off it or want, you know, weaning off it or whether they’re happy to stay on it a bit longer. And it would probably depend on their health overall. So if they’ve got low bone density or they’ve had some other change in their health we might consider continuing it longer.’

Professor Kulkarni, a psychiatrist specialised in women’s mental health, explained how she advises women who want to stop HRT.

Further information

Talking Points (Health Practitioners)

Talking Points (Women)

Other resources