Welcome to our guide for surviving surgical menopause. Congratulations for setting out to learn more about your body and her needs in this challenging time!

Because this site uses blogging software, this home page can be a little confusing and, frankly, isn't the best of places to begin reading. Instead, we suggest you begin by reading the "Introduction" tab above, and then move along to the "Table of Contents" page. Working from that to read one article after another in that order will make a great deal more sense for you. And don't forget, if you're looking for something specific, that there's a search field in the left side of the upper pink navbar. Still can't find what you need? Come join us on our forums and we'll try to help you out.

The redemption of HRT

Ding dong! The witch is dead! Or, at least, the witch-hunt over hrts.

The beginning lay, catastrophically, with the cancellation of the Women's Health Initiative Study in 2002. There was a huge worldwide panic in the press, with the end message that using HRTs caused breast cancer. An immediate response followed, in which roughly 50% of the women in the US stopped taking HRT. Over time, attempts were made to suggest other ways of interpreting the data and stances softened, but the basic message persisted: HRT was too dangerous to use.

Whilst HRT supporters continued to explore how hormonal support in menopause, especially surgical menopause, could still be safely used, the costs began to accrue. Studies have suggested that nearly 50,000 women in the US, who were in surgical menopause and quit HRTs because of the study-related panic, died due to that decision.

Further, there were significant fiscal costs both to women and to the general economy from the morbidity due to hot flashes and other untreated menopausal issues. Between 1999 and 2011, says one study:
Women with hot flashes used more healthcare services, particularly outpatient services, than women without symptoms, the researchers found. The extra services added up to $1,336 more per person per year compared to women without symptoms, and the indirect economic loss due to missed work was an extra $770 per woman per year.
Additionally, the authors of that study attributed about $300 million in losses per year to untreated hot flashes, and for the full population of the US, expand that loss estimate to $billions. In Europe, a similar study/estimate suggests a loss of more than €100 million per year just in the Netherlands alone.

But misery isn't measured in currency or even deaths alone. The vast number of women untreated and told to swallow their symptoms because they were "just depressed" or otherwise had failed at talking themselves out of anything more than "a few warm spells" (the classic medical description of menopause presented by many doctors) cannot be counted. But we felt it and we saw it in the discussions online amongst the menopause community, as women struggled to make sense of their symptoms in a climate that forbade them treatment and turned the blame back on themselves. At best, we hoped that with time the more sensible interpretations of the study outcome would take hold and those stances would soften in the decades ahead.

A shocking statement

And that's how things continued until March of 2017. That's when a startling review article was published in Climacteric, the journal of the International Menopause Society, by R.D. Langer, whose background is cited as:
The author was the Principal Investigator for the WHI Vanguard Clinical Center at the University of California, San Diego for the entire primary study period from 1993 through 2005, Chairman of the WHI Principal Investigators Committee from 1994 to 1995, a member of the WHI National Steering Committee from 1994 to 2005, and Chairman of the WHI Observational Study Scientific Advisory Committee from 1996 to 2005. 
Here's the full citation:

R. D. Langer (2017): The evidence base for HRT: what can we believe?,
Climacteric, DOI: 10.1080/13697137.2017.1280251

Basically, the author asserts that many of the research team were shut out of the decision to publish the initial WHI results (study cancellation) paper and were given neither time to review the release nor comment upon it. Further, the timing worked out such that the press release came out before anyone capable of reading the results could have access to them. And, finally, the press release itself was manipulated to emphasize the breast cancer risks...even though they did not exist when the data was correctly analyzed. The author summarizes in terminology rare in the medical press:
The unmistakable and deliberate focus of the small group of self-appointed authors was to trumpet a finding of harm from breast cancer – the science and statistics notwithstanding. This was deeply embedded in the paper and emblazoned in the press release.
The author concludes:
The WHI trials were soundly designed to address the questions the program was intended to answer, with planned procedures duly noted in the protocol. That good science became distorted and ultimately caused substantial and ongoing harm to women for whom appropriate and beneficial treatment was either stopped or never started. Key faults have included: failure to properly identify the study goals and population characteristics in presenting and interpreting the results; inappropriately generalizing the findings to a key sub-group – newly menopausal women – that was not adequately represented; inappropriately generalizing the findings from specific medications to an entire class; failure to put the findings in the context of existing knowledge (taking the position that the prior studies were simply wrong); favoring publicity, fear and sensationalism over science; and departing from protocol – focusing on unadjusted results, while avoiding planned analyses with proper adjustments and better statistical power.
That's pretty powerful stuff, isn't it? Basically, the WHI-mediated panic was an historical blip. But although we saw a followup editorial or two, it certainly escaped notice in the popular press.

Where could we expect to go from there? At the time, in presenting it to our discussion group, we suggested:
As women, we can work to correct the misunderstandings of women and we can bring this review of Langer's to the attention of our doctors when they insist upon the dangers of hrt. It took mere moments for this disaster to unfold upon us women in menopause; it will likely take decades before the damage is undone, especially amongst the doctors who will resist any updating of their opinions. 

But then!

Well, as it turns out, we were wrong and we couldn't be happier about that.

Although they released the news on a major US holiday weekend, the North American Menopause Society, one of the most conservative of guideline-publishers and one of the ones to jump most thoroughly on the take-hrt-and-die post-WHI bandwagon, published a new set of menopause treatment guidelines that totally revises their stance on HRT use, even in women with the BRCA mutations and even on use by older women.

Here's an article summarizing the new statement:
Don't Be Nervous About Hormone Therapy for Menopause, Says NAMS (free signup required to read)

And here's The 2017 hormone therapy position statement of The North American Menopause Society in its journal abstract and in full.

What it says

First of all, the position paper states its applicability:

Key to initiating or continuing HT in an individual woman is an understanding of the benefits and risks of age at initiation or time since menopause, specific formulations or types of HT, the duration of therapy, the need for monitoring during therapy, potential risks of continuation, and the need for shared decision making.
The use of HT is considered for different cultural or minority populations of women, including those with surgical menopause, early menopause, or primary ovarian insufficiency (POI) and for women aged older than 65 years.
The paper also cites the scientific foundation for its conclusions:
based on material related to methodology, a review of key studies and evidence-based literature, and presentation and synthesis of evidence. It was written after this extensive review of the pertinent literature and includes key points identified during the review process. 
And they provide another whole document of the actual scientific background, should anyone want to consider the basis for their points. This may not mean a lot to you, but it's part of establishing how and why doctors can take faith in this as "evidence-based medicine." In other words, they've got the evidence in spades...or at least 58 pages worth of it.

The statement as a whole is fairly clearly composed and not difficult to read and we encourage women to read it for themselves. There are key points identified and clearly listed out after each section, and we for the most part agree with all of them. Perhaps startlingly, there's very little in there that's actually new or different from our own understanding, carefully sifted from research and consideration and spelled out here on the site.

Amongst the things that did catch our eye, however, was the reference (p6, vasomotor symptoms) to a 300 mg dose of progesterone:
Micronized progesterone 300 mg nightly significantly decreases VMS (hot flashes and night sweats) compared with placebo and improves sleep. Synthetic progestins have also shown benefit in studies. No long-term study results are available.
We're a little wary of that one because of the risk of depression and vertigo with doses like that, not to mention the risk profile suggested in research about breast and cancer risk. For a lot of women, this wouldn't just "improve" sleep; it would be akin to general anesthesia! So we look at the "no long-term study results" as an important flag on this one, not to mention years of women's attempts to follow Dr. John Lee's advice that the more progesterone a woman can take, the better she'll be (spoiler: we have found many women's experiences to disagree strongly with this). In fact, elsewhere in the statement is the concession that high doses of progestins may be associated with depression.

We're pleased to see that in general, NAMS is distinguishing between the effects of oral as opposed to transdermally-delivered HRTs. This is big, not the least of which is because for years Premarin was taken as being synonymous with all HRTs and thus tarred all HRTs with any effect of either its specific formulation or its delivery route.

We're also pleased that this paper recognizes that women who have a hysterectomy with retained ovaries often experience subsequent early menopause:
For women whose ovaries are retained at the time of hysterectomy, there is a two-fold increased risk of ovarian failure, and 20% or more of these women may develop symptoms of diminished ovarian reserve within 1 year 
Many women have been denied HRT following a hysterectomy because they nominally still have ovaries. Documenting that those ovaries may experience reduced output can make a great difference for these women. We've known about this statistic for years, but judging by the number of women complaining about this situation, not as many doctors as we might hope do.

And for those who have had an oophorectomy, there is no longer a "wait and see if you need it" (which we've always felt rather meant "demonstrate enough suffering to show you deserve it") aspect. The guidance is clear:
Unless contraindications are present, ET is indicated for women who have had a bilateral oophorectomy and are hypoestrogenic to reduce the risk for VVA and dyspareunia and osteoporosis, with observational data suggesting benefit on atherosclerosis and CVD, and cognitive decline and dementia.
The paper notes that estrogen has been demonstrated to reduce joint pains and stiffness. That's something that women have been told for years was not and could not possibly be related to menopause, leading to lengthy diagnostic journeys through the autoimmune disease realm. Once more, women's experiences are validated here, and that should vastly improve our ability to be successful in advocating for and obtaining appropriate treatment.

Finally, there is a demonstrated improvement in quality of life with HRT that may make the risks of HRT acceptable. What a notion! Women want to feel well and they're willing to accept some risks to do so. Again, this is quite in keeping with what we have seen women pleading for during the whole WHI brownout on HRT.

In the area of osteoporosis, there are no surprises other than the endorsement of HRT for preserving bone density. Of interest, however, is the statement that "Bone protection dissipates rapidly after HT discontinuation, but no rebound in fracture risk has been found." This suggests that when women finally do decide to quit HRT, they aren't going to immediately shatter. That doesn't negate the need for good bone maintenance practices throughout menopause, but it gives some hope that relinquishing HRT doesn't automatically mean going onto a bisphosphonate.

One important area this position paper identifies and begins to clarify is what women with hormone-related cancers should do.
For women with breast cancer, low-dose vaginal estrogen should be considered and prescribed in consultation with their oncologists.
Note that this doesn't default to an OB-GYN or family doctor. This is specialty territory, and so this is where we need to turn to an oncologist. If you've been forbidden HRT because of a vague "family history" of cancer, you deserve a full and detailed workup of your history and actual genetic risks rather than depending upon something Aunt Martha said once. And if you have been treated or are now being treated for breast cancer and are in pain from GSM (formerly known as vaginal atrophy), this holds out considerable hope that you might be able to use this most effective treatment if nonhormonal measures have been unavailing.

With respect to genetic risk for cancer,
Limited observational evidence suggests that HT use does not further increase risk of breast cancer in women with a family history of breast cancer or in women after oophorectomy for BRCA 1 or 2 gene mutation.
But for women who have or who have had breast cancer, the outlook remains unfavorable:
Systemic HT is not recommended for survivors of breast cancer, although selected cases with compelling reasons may be discussed in conjunction with an oncologist after nonhormone options have been unsuccessful.
More detailed analysis of risks involved with lung, colon, and ovarian cancer are in the statement, but women concerned about those areas definitely need to read the statement itself.

And this is the summary given of their overall evaluation and advice:
Hormone therapy formulation, dosing, regimen, route of administration, and the timing of initiation of therapy likely produce different effects, although these have yet to be evaluated in head-to-head RCTs, and there is a significant difference in the benefits and risk of estrogen alone compared with estrogen combined with different progestogens, at least as studied in the WHI. The concept of ‘‘lowest dose for the shortest period of time’’ may be inadequate or even harmful for some women. A more fitting concept is ‘‘appropriate dose, duration, regimen, and route of administration.’’ Given the more favorable safety profile of estrogen alone, longer durations may be more appropriate. Risk stratification by age and time since menopause is recommended. Transdermal or lower doses of HT may decrease risk of VTE and stroke.
We want to underscore this notion of ‘‘appropriate dose, duration, regimen, and route of administration.’’ This pretty much adopts an individualized evaluation of a woman's situation and goals as the standard, rather than an arbitrary "best" HRT or dose or age guideline. This is big. This is great. This is going to take some work within the fundamentally patriarchal field of medicine, but oh, what a wonderful goal.

And who agrees with it?

The new NAMS statement includes a lengthy list of endorsements quoted at the end, and we are copying this out just to demonstrate how widespread this revision of the "party" line now is:
This NAMS position statement has been endorsed by Academy of Women’s Health, American Association of Clinical Endocrinologists, American Association of Nurse Practitioners, American Medical Women’s Association, American Society for Reproductive Medicine, Asociacio´n Mexicana para el Estudio del Climaterio, Association of Reproductive Health Professionals, Australasian Menopause Society, Chinese Menopause Society, Colegio Mexicano de Especialistas en Ginecologia y Obstetricia, Czech Menopause and Andropause Society, Dominican Menopause Society, European Menopause and Andropause Society, German Menopause Society, Groupe d’e´tudes de la me´nopause et du vieillissement Hormonal, HealthyWomen, Indian Menopause Society, International Menopause Society, International Osteoporosis Foundation, International Society for the Study of Women’s Sexual Health, Israeli Menopause Society, Japan Society of Menopause and Women’s Health, Korean Society of Menopause, Menopause Research Society of Singapore, National Association of Nurse Practitioners in Women’s Health, SOBRAC and FEBRASGO, SIGMA Canadian Menopause Society, Societa` Italiana della Menopausa, Society of Obstetricians and Gynaecologists of Canada, South African Menopause Society, Taiwanese Menopause Society, and the Thai Menopause Society. The American College of Obstetricians and Gynecologists supports the value of this clinical document as an educational tool, June 2017. The British Menopause Society supports this Position Statement.

How will this affect me?

If you're already taking HRT, relax. We still have data that suggests that our lowest effective dose still relates to least risks, especially with regard to combined HRT (estrogen + progestogen). But we also know that "lowest" really means the one that makes us feel the way we define "well" in menopause to be. With the new statement, though, we no longer have to fight off our doctor's insistence that we stop HRT after five years of use (a disastrously simplistic reading of the original WHI study cancellation report) or, really, at any particular age milestone. That cap is lifted and it's now supported that we can continue to reap benefits from ongoing HRT use. We'll still argue that we need to reappraise our level of need for supplementation as we age , but that's just housekeeping.

If you quit HRT and are now thinking about going back on it to regain its benefits, sorry. It's still felt that the evidence is strong enough, even for transdermal HRTs, that they raise clotting risk enough that if we have been off of them for any substantial time (something like a matter of months), our risks upon resuming are not adequately offset by benefits. This may be negotiated according to amount of time and the quality and quantity of our symptoms, though, so it's not yet an absolute ban. We may see this thinking revisited in time and we'll let you know if we see anything that changes that position, but for now, "no" seems to be the authoritative word. But even if we've stopped systemic HRT, don't forget that we can continue using vaginal HRT to support those local tissues and functionality without that concern.

If you want to take HRT and your doctor says no, it's too dangerous and gives you cancer, this statement provides your best argument, hot from the medical press and international approval. But remember, our doctors are busy and even if they have time to read journals, this may still be beyond their usual subscription list. So feel free to share the link to the position statement and call attention to the fact that so many international agencies have endorsed it. We don't want to suggest that your doctor is behind the times, but *cough* they may not have gotten there yet.

And for the sake of all women in menopause, we can bring this up in conversation. While women often conspire in a general silence about menopause (no, we don't know why and it makes no sense, really), so much of the WHI-related anti-HRT panic was passed along woman-to-woman. So now we can reverse this trend by talking with our fellow women when the topic arises and make sure that if they are not comfortable in their menopause, they know about this latest information on HRT and recommendations for its use. We focused so long on its dangers, and that totally caused everyone to lose sight of its benefits. We finally have solid ground that we can use to help turn that conversation around.

The Cenestin-Enjuvia discontinuation quandary

With the recent reports that these two HRTS have been taken off the market, we've had an influx of women joining our discussion group asking what they can take to replace them.

That's not an easy question to answer. In part, the answer depends upon just why each woman chose that HRT and continued to take it. So let's look at some of the ways we might end up with this particular blend of conjugated estrogens and consider where we might go from there.

The first one they tried

For women who took one of those brands simply because that's the first one their doctors gave them and it seemed to work okay, this presents an important opportunity to actively choose and try out other hrts. We've put up a simple framework and supporting aids for working through this process based upon each woman's own priorities, not whichever drug rep most recently pitched their product to our doctor. If we work though the selection process, choosing an HRT that meets our own preferences and lifestyle, our doctors should honor that request. And because we've done our homework beforehand, we're prepared to state just why we're making that request, which factors are important to us. We may not have success with our first try or our first try may need a bit of tweaking, but we have to start somewhere. The good news is that this process is easier moving from the stability of a good solid HRT foundation than if we've just had surgery or have been in a state of hormonal uproar.

Alternative to Premarin

If a woman chose this HRT as an alternative to the Premarin that their doctors were urging on them, no, there is not another alternative. There is no other vegetable-source HRT on the market that provides conjugated estrogens. If your doctor is Premarin-or-nothing and will not countenance your using a different type of HRT, the other option is to find a more reasonable doctor who is willing to let you make the critical decisions about your own body and health. Or take Premarin. Even though Premarin is likely to provide for a somewhat different experience, it may work acceptably if one of the others previously did. That assumes, of course, that one is not a vegan or does not have ethical objections to its manufacture.

Tried everything

If women came to this HRT after hopping from one brand and type to another, taking each one at one dose for a short period of time and then, because that one didn't fit, moving on to another, it may be time to reflect upon that process. It often happens that the first dose of an HRT we take doesn't thrill us, but if it does demonstrably deliver to our bodies, we can often tweak the dose or application mode to provide a better fit. When we instead simply jump to another HRT and then another, we pile up the stress of all of those imbalances on top of an already stressful lack of estrogen, leaving us in a deeper and deeper hole we've got to dig back out of.

We've written elsewhere about the process of choosing and tuning an HRT, and while it's not instant gratification, we're all capable of the self-observation skills to carry this out. This may be a good time to revisit this basic selection process, think about which formerly-tried HRT really seemed as though it might have been a good fit for our lifestyle, and revisit it for another attempt. It's very important to remember that if we did this hopping in the first few months after a hyst, we were adding the hugely stressful burden of the menopausal transition to all of the things going on in our bodies, and in a changed setting, months or years later, our overall response might be changed as well.

Prefer oral

If a woman came to this HRT simply because they wanted an oral HRT, a pill they could pop and not worry about it, then reviewing the list of HRTS available in the US (this issue does not affect those using UK HRTs since there was not a non-Premarin conjugated estrogen sold in this market) will show you your options. While this delivery has been less popular in recent years because of its greater risks for cardiovascular disease and cancer, it remains a valid choice for women who are willing to accept that risk profile or who have found that most transdermal deliveries don't work effectively for their bodies.

Uncomfortable with estradiol

While the majority of women today use estradiol HRTs, that contain this active form of estrogen, there is a body of women who find this much activity in a dose excessively stimulating. While we can speculate about genetic variants in metabolism, we don't really have any good explanation why this affects some women but not most others. Nonetheless, after giving more than one estradiol at more than one dose a try, these women just can't settle in. In the end, an HRT that is more estrone-based (the less active, storage form of estrogen) seems to be more comfortable for them.

Unfortunately, there are not a lot of options for these women. Some of the estrone options will be sold as "piperazine estrone sulfate" (formerly known as estropipate), sold as brand names Ortho-Est and Ogen, or "esterified estrogens", sold as the brand name Menest. It's not clear how many of these remain on the market, but women are successful in finding them from time to time. Probably the best tactic, since this availability is not something your doctor will be able to advise you on, is to call around to pharmacies to see if any of them carry or can order it, and if you find one, then ask your doctor to prescribe it for you.

The other option for an estrone-based HRT would be to have one compounded. While compounding pharmacies can make up all-estrone or an estrone-estradiol blend of any proportion for use by a variety of routes (oral, transdermal, transbuccal), women should be aware that the typical "bioidentical" prescription is a generic blend that is more appropriate for a woman in natural perimenopause and contains mostly estriol, a weak estrogen breakdown product effective only in urogenital tissues, plus a small amount of estradiol. This particular type of HRT is not likely to meet a woman's needs in surgical menopause. Instead, one needs to have a doctor prescribe either all estrone or a proportional estradiol/estrone blend to come closer to replicating something more like the conjugated estrogens that have been discontinued. Compounding pharmacies cannot make up a conjugated estrogen blend to match the discontinued HRTs because they do not have access to the components.

Prefer a synthetic estrogen

There are many factors that go into selection of HRTs, and some women may for one reason or another choose a non-human-identical estrogen. There is not another synthetic estrogen blend on the market, however. The most popular synthetics that are not Premarin are ethinylestradiol, a potent synthetic used in oral contraceptives, and tibolone, sold as Livial or Tibofem, that is a synthetic steroid drug with some estrogenic, progestogenic and androgenic activity. It is unlikely that either of these will provide for the same experience as the conjugated estrogens.

How to switch

Once you've made your choice, have your new HRT and are about to run out of the last of your Enjuvia or Cenestin, you might be wondering what the best tactic is for changing over. Luckily, it's pretty easy:

  1. Take your last conjugated estrogen pill.
  2. Wait 24 hours.
  3. Begin your new HRT.

It's as easy as that.

Now, because the conjugated estrogens aren't actually human-identical estrogens, it may take your body a while to fully metabolise them, especially if you've been taking them for years. So you may find that after a few days to a few weeks or even possibly a month or two, your new hrt, even if it felt great at the beginning, now doesn't feel as though it's quite such a good fit. Don't panic! This doesn't mean it's stopped working. It just means that you were still cruising on some leftover conjugated estrogens and now they're gone so they're not contributing to your total coverage any longer. And that means that you need to make a small bump in the dose of your new HRT. In this context, "small" generally seems to mean no more than about 10-15% of your dose, not doubling it. Too big a jump is not only uncomfortable in itself, but it risks taking us right past our best dose and into the risky and unpleasant territory of excess. So this is a case where being gentle with ourselves really pays off better in the long run.

One other question we often see has to do with how much of a dose we will need of our new HRT. In general, wherever we were in the range of available doses of our old HRT (highest, lowest, middle), that's where we start in the range of doses of our new HRT. That's just a guess and it won't be perfect, but a guess is as good as we can get when changing from one type of HRT to another. So we start there and then tune. If in doubt, it's almost always better to underestimate than overestimate, just because it's easier to identify and quicker and safer to play catch-up from.

The bottom line

Cenestin and Enjuvia are gone. There is no secret illegal internet pharmacy that can provide non-counterfeit versions of it. There is no immediate replacement that we can expect to work exactly the same way. This means that, one way or another, you're changing HRT.

In order to best do this, you need to identify your own situation and goals, pick a new option, and test it, including tweaking it if needed.

We can help you with this. Here are the links again for some of the specific resources we can provide:

And of course you're always welcome to come to our discussion group to talk through your own process. We can't tell you what will work best for your own body, but we can help you and keep you company as you explore the various options you have.

What we can agree on about hrts and what we still don't have any idea about

Two interesting documents have recently been released that can make a difference to how we, and our doctors, think about and use hrts.

First is the Revised Global Consensus Statement on Menopausal Hormone Therapy. You can read the full version online here and here, and it's worth doing so because the language is clear and to the point, the article itself brief.

What this represents, as the article clearly states, is what a whole whack of international expert societies on menopause can all agree on. It may not cover everything each one specifically states, but it's the fundamentals they all accept as proven today. And that's important: these are proven points, not things still up for discussion or demonstration. And so if your doctor doesn't know these things or disagrees with them, he's disagreeing with what the specialists in the field accept as proven. There's always room for personalization, but if he's still arguing about this stuff and can't explain why it doesn't apply to you, you may be receiving outmoded care.

What's exciting for us in this? Mostly, that this includes a number of points we've been making for years.
The type and route of administration of MHT [Menopausal Hormone Therapy] should be consistent with treatment goals, patient preference and safety issues and should be individualized. The dosage should be titrated to the lowest appropriate and most effective dose.
Note the "patient preference" part in there. As well as the "most effective" in with the "lowest" point.
Duration of treatment should be consistent with the treatment goals of the individual, and the benefit/risk profile needs to be individually reassessed annually. This is important in view of new data indicating longer duration of VMS [hot flashes] in some women.
See what the main standard is there? the "treatment goals of the individual." That means that if we say we need it, we do. Yes, it's right to check this every year and try out a lower dose from time to time, but no longer is there any excuse for an arbitrary age or cumulative time cut-off.

And, finally:
The risk of breast cancer in women over 50 years of age associated with MHT is a complex issue with decreased risk reported from RCTs [clinical trials] for estrogen alone (CE [Premarin] in the Women’s Health Initiative (WHI)) in women with hysterectomy and a possible increased risk when combined with a progestin (medroxyprogesterone acetate in the WHI) in women without hysterectomy. The increased risk of breast cancer thus seems to be primarily, but not exclusively, associated with the use of a progestin with estrogen therapy in women without hysterectomy and may be related to the duration of use.
Note that although they identify the one progestin that there's solid clinical data for, they leave the question somewhat open. Thus we begin to see that the risk of all progestogens is gaining in credibility. "Just because" is no longer sustainable in hrt prescribing, especially for women who have had a hysterectomy.

Here's the full citation and doi number if you want to share this and it's not convenient to download one of the pdf versions linked above:
ISSN: 1369-7137 (Print) 1473-0804 (Online) Journal homepage: http://www.tandfonline.com/loi/icmt20
Revised Global Consensus Statement on Menopausal Hormone Therapy
T. J. de Villiers, J. E. Hall, J. V. Pinkerton, S. Cerdas Pérez, M. Rees, C. Yang & D. D. Pierroz
To cite this article: T. J. de Villiers, J. E. Hall, J. V. Pinkerton, S. Cerdas Pérez, M. Rees, C. Yang &
D. D. Pierroz (2016): Revised Global Consensus Statement on Menopausal Hormone Therapy,
Climacteric, DOI: 10.1080/13697137.2016.1196047
To link to this article: http://dx.doi.org/10.1080/13697137.2016.1196047

Could precision prescribing of estrogen be achieved?

This is the second interesting article, one that one of the members of our discussion group just shared with us all: Post NICE Guidelines: could precision prescribing of estrogen be achieved?

In a way, this article also says the things we've been saying for years about the fact that while the drug information data for hrts suggests that they are drugs of a "one size fits all" sort, personal experience of women is varied and confusingly individualized. In short, it basically says that different women have different needs and to best meet them, you need to give them different things. And by the way, lab tests are rubbish at figuring all of this out.

Groundbreaking stuff, this.

Okay, while we'd like to just be snotty along the lines of it being about time doctors were catching on to what women have been trying to tell them for so long, it's actually good, in the ponderous, over-proven way that medical consensus moves, that these things are being said. Again. Because if we say it, we're just poor ignorant deluded women; if doctors say it, it is thought-provoking and reasonable...and may eventually make a difference. And that's the real importance of this article: that doctors are saying that there's more to using or prescribing hrt than thinking of it as an interchangeable drug.

Also, we wanted to throw up our hands and cheer at this paragraph—or, actually groan with the truth of it:
The NICE guidelines have been published at a time when investment in research into women's health has evaporated, not only because of desertion of commercial money but fundamentally because the funding in this area of research is not attractive for voters and, indeed, many opinion leaders in those policy-making circles believe that the menopause and its associated symptoms are women's destiny and they have to cope with it.
We don't entirely like his conclusion that women should fund this needed research, but we have a sneaking suspicion that we're looking, right here, at the future of medical research: if you want it, you have to invest in it. And when haven't we women, in the end, had to do things for ourselves?

The "problem" of bioidentical HRTs

Medical news services are full, lately, of articles decrying recent surveys indicating the popularity of compounded HRTs (one, two). With figures showing use statistics varying from 28-68% of HRT users choosing compounded (so-called "bioidentical") HRTs, this represents a significant loss of income to physicians. Dismay over this loss is cloaked in a variety of concerns, typically that these HRTs are not FDA-approved and that they come without boxed warnings, but the subtext is very clearly "but they didn't get them from US" or even more blatantly "but they didn't do this OUR way." And the tactics suggested in the more instructional of these articles focus primarily upon creating fear and shame in these straying patients.

What seems to be substantially missing from the medical professionals' side of the discussion is any attentiveness to why women have made this decision and how medical practice could address those concerns better. "Personalized" is what a lot of the comments come down to, but that's not the full picture we see in our discussions with women.

Women talk about things like how they're seen as noncompliant when the stock HRT their doctor offers them doesn't suit their needs or even their lifestyle. Women talk about being rebuffed with "I can't help you" or "I don't do that" when they ask for a different HRT brand or route or dose as they struggle to find their way in an opaque and guideless wilderness of choices. Women take articles they've found from medical journals or medical specialty group consensus documents to appointments to discuss latest findings and guidelines and are waved off with "I know everything I need to about HRTs." Women who have had cancers find discussions of their hormone needs flatly dismissed with the notion that it is ungrateful, their lives having been saved from cancer, to want to enjoy those lives with some quality of comfort. Women disabled by symptoms are frightened when those symptoms are waved off with an "I gave you HRT so it can't be your hormones" and the blame turned back on them. Women in surgical menopause, who understand that this is a different entity to natural menopause, are unable to establish trust with health professionals who insist that their symptoms are simply self-indulgence and that "a few warms spells and it'll all be over." And women who have been taught that medicine is evidence-based are dumbfounded to find that there are no tests to guide their way and no objective standards that can be applied beyond "the FDA says this drug works" when a particular HRT manifestly doesn't for them.

There is a vast gulf between what doctors want—customers—and what women in menopause want—health—and everything in the current discussions seems to indicate that doctors are not willing to bridge that gap. Is it any wonder, then, that advertising claims of customization, personalized care, attentive adjustment of HRTs, "natural" treatments, and safety—no matter whether justified or not—are winning out with these customers in the face of the "do it our way or no way" approach they feel they are receiving from their medical caregivers?

It can be argued that menopause is really a poor fit for allopathic medicine in the first place, that being, by definition, the diagnosis and treatment of disease. What women in menopause want is not to be labeled with a disease requiring treatment but rather a way to maintain their health in the face of a lifestage change that alters their health, comfort, and risks profile. For all that is good and bad in the compounded HRTs industry (and we have many thoughts on that), that's what is, in the end, the perception of the product being sold. Women are no longer the dependent, easily-influenced, uninformed 50s-era housewives who hang upon their doctors' guidance: they're smart, educated, doing their research, and willing to shop for what they feel they need. And until doctors and other prescribing professionals can address this opportunity in a constructive manner that actually addresses these women's needs, this situation isn't likely to turn around.

In the end, it doesn't matter which HRTs are fully licensed or which of the compounders' claims are bogus. What matters is that those practitioners are saying to women: we hear you; we believe you; we'll work with you. And until medicine can do that, can meet menopausal women from a point of respect, it is likely to continue to hemorrhage patients to more receptive practices.