Is HRT safe? Experts weigh in.

For decades, there has been an ongoing debate over the safety of HRT. So what's the final answer?
Mature woman fanning herself to cool down

Speak to any woman in the perils of mid-life hormonal changes or considering HRT and you begin to wonder how far we’ve really come. In ancient Greece, one floating theory was that women suffered ‘hysteria’ because their empty uterus was in mourning. By the 1700s physicians thought women’s brains were controlled by their ovaries. Schlep forward slightly to the Victorian era and ‘climacteric insanity’ was a one-way ticket to an asylum. (Particularly if you were also partial to a glass or two).

And now? Women are still more likely to be offered anxiety or depression medication than hormonal therapy for perimenopausal symptoms. In fact, the stats show that, regardless of what prompts a GP visit, we face higher odds of being diagnosed with a mental health condition than a man, even if we go in with identical physical complaints. It begs the question – is the needle still stuck on hysteria?

In all fairness, we are pretty quick to declare ourselves bonkers when things aren’t ticking along as they used to.

“I suddenly felt so anxious about everything,” says mother of two, Lucy Brooks, whose period unexpectedly stopped at age 42.

“I very swiftly went from being active, happy and gung-ho, and managing kids, marriage and my own business, to not being able to cope with anything. My sleep went to pot. I was crying in the shower. I had no sex drive. I was forgetting things. I felt so unattractive and my confidence dropped. My GP who I had been seeing for a long time assured me I looked just the same and suggested I try anti-depressants.”

Woman sitting on front verandah with a tired expression

It’s an all-too familiar story for many women in the throes of midlife. Rebecca*, 48, became so anxious in her mid-forties she felt she had no option but to give up her career.

“My brain felt like a swamp. Things I used to do without batting an eyelid very difficult all of a sudden. Even packing the kid’s lunch was total overwhelm. I got so bad that, if you asked me what we might do for fun on Saturday, I would burst into tears. I felt ridiculous and inadequate because I had given up my job and nothing else in my life had changed. It was just me.”

Riddled with frustration and a burdening sense of shame, Rebecca took a checklist of symptoms to her GP. Hair loss, acne, weight gain, anxiety, headaches, night sweats, constipation, joint aches, debilitating gut symptoms and brain fog.

“I burst into tears and asked for HRT. She said, first of all, it sounds like you have depression.” Two previous doctors had concluded the same, but this time Rebecca remained insistent and left with an HRT prescription.

Directly asking why you haven’t been offered HRT for perimenopausal symptoms is something Dr Louise Newson, a GP and Menopause Specialist in the UK, strongly advocates doing. She says the mental symptoms (low mood, anxiety, memory problems and reduced motivation) are more common than hot flushes for many women.

“While I can see how menopausal mood changes could be mistaken for clinical depression, there is no evidence that antidepressants help to improve the psychological symptoms of the perimenopause and menopause. To ease symptoms, you need to get to the root cause: low hormones. And what is the first line treatment to ease those symptoms? HRT.”

What is HRT?

In defence of GP’s, it has hardly been a fashionable prescription for the past two decades. In 2002 the Women’s Heath Initiative (WHI) study was halted prematurely because of HRT’s suspected links to breast cancer. Doctors understandably stopped recommending it.

“The women’s health study scared the living daylights out of everyone,” says Dr Jasmina Dedic-Hagan, a GP and functional medicine doctor with a special interest in women’s health. “I remember it well. My patients remember it well. It’s a conversation I still have.”

The long shadow cast by the gripping headlines still hasn’t lifted. Partly because the research (or lack thereof, some would argue) is ongoing. According to Dr Newson, a more detailed analysis of the WHI study showed the link between breast cancer and combination HRT was not statistically significant.

“In fact, estrogen-only HRT was subsequently shown to be associated with a lower risk of breast cancer,” says Dr Newson. The synthetic hormones used in this study were also very different from the body-identical hormones that are available now. “Newer types of HRT are the body identical oestrogen, progesterone and testosterone, which are derived from the yam plant,” says Dr Newson. “These have the same molecular structure as the hormones you produced naturally from your ovaries when you were younger.”

Naomi Watts discussing menopause on a visit to Sydney in 2023
Recently, Naomi Watts said she thought of menopause as “equating to the end” of her career.

That doesn’t mean taking hormones comes without any risk at all. Any substance you take, natural or synthetic, can have unwanted side effects. And, even in medical circles, there isn’t a unified consensus on the risks and benefits. That’s because the risk very much depends on your individual health factors, as well as the type of HRT you take.

“It’s about you as an individual. Your family history, your medical history, your preferences, your choice,” says Dr Newson. “HRT is available in lots of different doses and types. What might suit your best friend or sister may not necessarily work for you.”

Does HRT cause cancer?

A recent 2019 study of women aged 50-69 found that breast cancer risk increases from 6% to 8% if you take HRT. While that is statistically significant, Dr Dedic-Hagan says it’s worth looking at the figures in perspective. Other research indicates this is less than the increased risk from drinking 2 or more units of alcohol a day, or having a BMI over 30.

“Also, what we don’t hear about is that exercising for 2.5 hours a week can reduce breast cancer risk,” says Dr Dedic-Hagan.

Knowing whether you need HRT can be the tricky part if you’re still menstruating because symptoms can fluctuate dramatically. That in itself is a perimenopause symptom.

“It used to be that you had to do your suffering – a full 12 months without your period – to finally get the certificate that you have suffered enough,” says Dr Dedic-Hagan. While you can go and get your hormone levels tested, neither medical expert says this is useful (unless you are under 40 and thus possibly in early menopause) because hormones change daily, even hourly. They suggest the physical and mental symptoms, rather than numbers, tell the story.

If you opt to try HRT, Dr Dedic-Hagan recommends doing so within 5 years of your periods stopping. “The body still knows how to deal with estrogen. After 10 years of menopause your body hasn’t met that kind of level of hormones in a long time and has downregulated.”

How long you should take HRT for is also a contentious topic. Some medical experts recommend coming off it as soon as you can, others see no harm in taking it for decades.

HRT advocates like Dr Newson say HRT can also safeguard against future health issues. “Body-identical HRT usually lowers cholesterol,” says Dr Newson. “Women taking HRT have a lower risk of developing heart disease, osteoporosis, type 2 diabetes, dementia, bowel cancer and clinical depression. We need to rid this idea that taking HRT is somehow giving in. It’s not. It’s simply giving your body back what it needs.” Recent research shows that women’s brains ‘rewire’ during the transition to menopause. This has prompted some academics to suggest that HRT could function as a protective measure for brain health too.

Woman with eyes closed smiling holding her hands up to her temples

For Lucy, the fear of taking HRT was very real. “I just thought, no, I don’t want to die of breast cancer. So I battled on with brittle nails, bloating, mind fog and feeling generally miserable.” The script sat in her kitchen drawer for 9 months before she found the courage to give it a go.

“I did some reading to educate myself and I realised that I really don’t want to feel flat and not be able to cope when there is something that might help.” Having been on it for over a year now, she describes herself as an “HRT warrior… Honestly there are so many women around my age wanting to divorce their husband, who keep crying, can’t cope with the kids, and suffer all these sensitivities. HRT doesn’t solve everything, but it has taken the edge off the big stuff. I have none of those symptoms now. I feel great.”

How long does it take HRT to work?

Medical professionals advise it generally takes 6-12 weeks to see a noticeable effect. But Rebecca says it was less than 10 days before she felt more like her old self. “The lights came back on and the swamp in my brain disappeared. I know this sounds ridiculous but I felt like everything was clearer, even my breathing. Like I wasn’t stuck in a haze anymore.”

After several months using a daily estrogen gel and a micronised progesterone pill for half of every month, she credits HRT with stabilising her home life. “My marriage wouldn’t have survived another six months. Even the kids were wondering what was wrong with me… But since taking HRT I am able to deal with stress better,” says Rebecca. “Today is one of the hardest days of my life… I have to put my father in a nursing home but I actually feel like I can cope.”

While taking hormones can improve both physical and mental symptoms, Dr Dedic-Hagan cautions against approaching HRT as a magic pill. Mid-life is tough going on all fronts. The juggle of work, kids, marriage, mortgages, aging parents and a generally high cognitive load means you might feel stretched regardless of what your hormones are doing.

“HRT can help you shift your energy but it’s not a Gaffa tape that holds it all together. You need to look at the whole picture,” says Dr Dedic-Hagan. “Maybe continuing as you have been is no longer the best thing for you and your body is trying to tell you this. This is not a scientific study but in my practice I find that the women who say perimenopause is a breeze are those that have more time for themselves.”

That, however, can be the greatest struggle of all. Putting your own needs and wants higher up the chain can disrupt the usual order of things in relationships, families and at work. “Is this why we are considered to be going ‘mad’?” says Dr Dedic-Hagan. “When you hit 50, it can really sink in. You have lived, at best, half of your life. What will you do with the rest? Menopause is an opportunity to walk out the other side feeling different in a positive way.””

*name has been changed to protect identity

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