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HRT: Why is it so damn confusing?
Why does HRT research feel like an extended episode of Succession? With all the stale, pale males jockeying for power while leaving the women out of the meetings? 🤦♀️
How the hell are you? Hold onto your hair. Lots to discuss this week!
So, before the mammoth New York Times menopause expose by Sue Dominus exploded like diarrhea on a plane, many of us were miserably slogging along (in coach, no less) at cruising altitude, suffering in polite silence.
(Brief aside: Can you imagine for one second, being that poor person? Going down in history as “poo plane person” the super pooper who caused an international inflight catastrophe with their bowels? I mean, we've all had to go before, but now publishers have to completely reissue the book Everybody Poops—dangerously in the sky! But I digress...)
As a result of Dominus’s amazing piece, it feels like we’re only now realizing there’s so much more to know about HRT and peri/menopause. We’ve been left out of the conversation for decades, but even with the data, it’s still confusing for a whole host of different reasons.
Last time on The Empress, we covered HRT and compounding for chronic conditions and allergies and how, in certain instances, it can save lives while in others, it can lead to dangerous outcomes if you are not working with a board-certified menopause specialist and FDA-approved pharmaceuticals. This week, we’re diving into why HRT research is still so confusing—primarily because there isn’t enough of it and the very way IT is compounded.
Broadly speaking, when it comes to peri/menopause, HRT, and research, we seem to have had a longstanding habit of… not looking closely—or at all. But menopause is so chemically all-transformative. Here’s the closest metaphor that seems to make sense. It comes directly from Katherine May, a writer I adore. I’m paraphrasing here, so forgive my flaws:
I used to imagine that a caterpillar’s metamorphosis into a butterfly was like a Michael Bay-style Transformer, reshuffling all of its mechanical parts inside the cocoon. Recently, I learned that it’s nothing like that at all. Caterpillars completely disintegrate and melt down into a biological broth—their own primordial soup— before certain cells cluster together again to form the butterfly. And it gets even stranger than that… If you zoom in even closer, the brain of a larva caterpillar is wholly different from the brain of the butterfly insect that eventually emerges. There’s literally and physiologically “no continuity of self.” It’s almost like they’re two entirely separate brains and beings.
When I read this, I immediately recognized my menopausal self-soup.
As noted nearly everywhere you look, the first clinical trials of HRT and chronic postmenopausal conditions didn’t start in the US until the late 1990s. If you go on PubMed and run a search for clinical studies on menopause hormone therapy, you will find 1,157 active records as of today. If you then run a search for clinical studies on testosterone therapy and erectile dysfunction, you will find approximately 34,191 active records. So, 3%? Someone correct my math here. We really don’t care about women.
But what shows up most noticeably when we DO study HRT is how we slice the data. We actually don’t. According to leading journalist Ann Marie McQueen’s phenomenal reporting at hotflash inc., most of the menopause studies look at HRT as a flat, whole, “without subdividing out bioidentical hormones versus synthetic hormones. And, while this might not seem like such a big deal when it comes to estrogen, it can make a difference with progesterone and the class of synthetics that are designed to mimic it, progestogens.”
We’re also not subdividing out testing of compounded custom solutions versus big pharma solutions to measure patient outcomes. Are patients experiencing markedly improved quality of life outcomes with more bespoke solutions? Or are the standardized solutions for certain cohorts meeting the patient’s needs in a meaningful and equally safe way?
We’re flattening all of hormone therapy into a single group—making it into a reductive Michael Bay mechanistic model when really it’s a complex primordial soup that holds the potential to be far more powerful and transformative for women. If we take the time (and the funds) not to flatten women and not to flatten the different solutions—then it’s possible we’ll arrive at much more nuanced outcomes and a set of data from which to make much smarter decisions.
There is also the issue that she and others (namely myself) have brought up, what if women have other risk factors, comorbidities, or chronic conditions? If we’re not looking at those variances as part of our research, what’s reflected in the studies may very well be a stale, pale male picture of things—and dangerous.
These are all issues that, while we press for more sophisticated studies, should still be discussed with your provider. If you find yours to be like mine, i.e., “It’s menopause, just take some birth control pills,” there are alternatives to consider like Winona, where you can connect with board-certified specialists in peri/menopause and FDA-approved HRT—like Dr. Kudzai Dombo and Dr. Cat Brown to work through the safest options and address specific questions that matter to YOU.
One more thing, we wanted to make sure you didn’t miss… One of the largest Menopause Studies by CELL was issued this past week and can be found here in its entirety. It’s a great deal to digest, but the folks at hotflash inc. have done an amazing job unpacking some of the finer points:
What's important to understand is that in this day and age, the truth can be a real trickster when it comes to how you slice and dice the data that supports that “truth”. And so, women need to own the narrative around the clinical research on their bodies. What does it mean to them? NOT what does it mean for Big Pharma and a bunch of stale, pale males? That way, we're not misled again and waking up a decade later to find ourselves on yet another stinky plane.
Welp, that’s the skinny on HRT research for today. I know it’s still confusing. Ultimately, it comes down to you, your symptoms, and your individual risk profile. But, we’re not done yet, so stay tuned for our next dispatch where we explore best practices for getting the most out of your HRT treatment—should you decide it’s a path you want to pursue.
Yours in Grandeur,
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