Increased awareness of menopause hormone therapy (MHT) has resulted in a growing demand for treatments, to the point where manufacturers are struggling to keep up. This has forced New Zealand’s drug-funding agency, Pharmac, to ration supplies temporarily.
Nowadays, most women are prescribed body-identical hormones, like transdermal estradiol (whether in patch or gel form) and progesterone capsules, to manage menopause symptoms such as hot flashes and night sweats. Estrogen alleviates these symptoms, while progesterone protects the uterine lining and may even aid sleep.
I think there are a couple of primary reasons behind this spike in demand. For one, there’s greater confidence in MHT thanks to reassuring long-term data from the Women’s Health Initiative trial and other studies. Also, conversations about menopause have become more open, with midlife women increasingly aware of available therapies and their potential benefits for bone health, which drives a demand for improved care.
However, supply shortages are not the only issue; substantial gaps in research and training for health professionals also persist.
Changes in MHT over time
The original Women’s Health Initiative trial’s results, published in 2002, initially frightened women away from MHT for years. The trial indicated a heightened risk of breast cancer, stroke, and blood clots in women taking combination hormone therapy for five years compared to a placebo. It also suggested that hormone therapy might not protect against heart attacks as previously thought.
That said, long-term follow-up data has brought some reassurance; the 18-year findings from the Women’s Health Initiative trial indicated no significant difference in overall mortality between those who took MHT for five years and those who received a placebo.
Research on transdermal estrogen treatments, like patches and gels, shows little to no connection with stroke and blood clots.
Clinical guidelines have evolved significantly since then. When I was training to be a gynaecologist in Canada during the late 1990s, we provided hormone therapy to all women. After the Women’s Health Initiative trial, though, we restricted it to those with the most severe symptoms. Eventually, we increased access again but limited it to lower doses for shorter durations.
Now, I advocate for MHT for all women experiencing menopausal symptoms after a comprehensive discussion of both the risks (primarily breast cancer) and benefits (like bone health). The current advice suggests using the necessary dose to completely alleviate symptoms. The treatment duration should be tailored individually, and the decision about whether to continue or stop should be reassessed annually between a well-informed woman and her healthcare provider.
Interestingly, MHT can now be regarded as the first-line treatment to prevent menopause-related bone loss.
Improving menopause care
These shifts have resulted in more MHT prescriptions than two decades ago. Following the initial trial results, prescriptions plummeted, and doctors became less practiced in prescribing MHT. Many new doctors didn’t learn about it, as menopause education was minimal in medical schools.
This situation means that some doctors might lack the training or experience needed to adequately discuss menopausal symptoms, prescribe appropriate treatments, and manage menopause effectively.
Currently, around four in ten medical schools in the UK do not include mandatory menopause education, and a survey indicated that most obstetrics and gynecology training programs in the US lack specific modules on menopause.
In response to the demand for better care, we have created a brief online training course focused on menopause care for nurses, nurse practitioners, and doctors, along with new content for medical students. We’re also pushing for more funded MHT options.
Nevertheless, there’s a distinct lack of research on women’s experiences in New Zealand. We have outdated data regarding who’s using MHT, what women seek from their healthcare providers, and how symptoms impact families and workplaces.
Most studies on MHT examine women who are already post-menopausal (12 months or more without a period). There’s a glaring absence of long-term, high-quality trials involving women in perimenopause—the transitional phase when symptoms begin—or women using contemporary MHT regimens, like those estrogen patches and progesterone capsules facing shortages.
Unfortunately, much of the guidance still relies on older studies that don’t accurately reflect New Zealand’s diverse population.
New Zealand introduced a women’s health strategy in 2023 aimed at “supporting women to live longer in better health,” with an emphasis on improving menopause support. Despite this, many women still feel dismissed by their healthcare providers.
We need research tailored to New Zealand on menopause, along with improved education and training for healthcare professionals. Midlife women are increasingly unwilling to accept undiagnosed or untreated menopausal symptoms.
